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Background: In China, the healthcare financing structure involves multiple parties, including the government, society and individuals. Medicare Fund is an important way for the Government and society to reduce the burden of individual medical costs. However, with the aging of the population, the demand of Medicare Fund is increasing. Therefore, it is necessary to explore the sustainability of the healthcare financing structure in the context of population ageing. Objective: The purpose of this paper is to organize the characteristics of population ageing as well as healthcare financing in China. On this basis, it analyzes the impact mechanism of population ageing on healthcare financing and the sustainability of existing healthcare financing. Methods: This paper mainly adopts the method of literature research and inductive summarization. Extracting data from Health Statistics Yearbook of China and Labor and Social Security Statistics Yearbook of China. Collected about 60 pieces of relevant literature at home and abroad. Results: China has already entered a deeply ageing society. Unlike developed countries in the world, China's population ageing has distinctive feature of ageing before being rich. A healthcare financing scheme established by China, composing of the government, society, and individuals, is reasonable. However, under the pressure of population ageing, China's current healthcare financing scheme will face enormous challenges. Scholars are generally pessimistic about the sustainability of China's healthcare financing scheme. Conclusions: Population ageing will increase the expenditure and reduce the income of the Medicare Fund. This will further affect the sustainability of the healthcare financing structure. As a consequence, the state should pay particular attention to this issue and take action to ensure that the Fund continues to operate steadily. [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: 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: The growing demand for LTC (Long-term care) services for disabled elderly has become a daunting task for countries worldwide, especially China, where population aging is particularly severe. According to CSY (China Statistical Yearbook,2019), the elderly aged 65 or above has reached 167 million in 2018, and the number of disabled elderly is as high as 54%. Germany and other countries have alleviated the crisis by promoting the public LTCI (Long-Term Care Insurance) system since the 1990s, while China's public LTCI system formal pilot only started in 2016. Therefore, the development of the public LTCI system has gradually become a hot topic for scholars in various countries, including China.Methods: This review has been systematically sorted the existing related literature to discuss the development of public LTCI (Long-Term Care Insurance)system form four aspects, namely, the comparison of public LTCI systems in different countries, the influence of public LTCI, challenge of public LTCI, and the relationship between public LTCI and private LTCI. We searched some databases including Web of Science Core Collection, Medline, SCOPUS, EBSCO, EMBASE, ProQuest and PubMed from January 2008 to September 2020. The quality of 38 quantitative and 21 qualitative articles was evaluated using the CASP(Critical Appraisal Skills Programme) critical evaluation checklist.Results: The review systematically examines the development of public LTCI system from four aspects, namely, the comparison of public LTCI systems in different countries, the influence of public LTCI, the challenge of public LTCI, and the relationship between public LTCI and private LTCI. For example, LTCI has a positive effect on the health and life quality of the disabled elderly. However, the role of LTCI in alleviating the financial burden on families with the disabled elderly may be limited.Conclusion: Some policy implications on the future development of China's LTCI system can be obtained. For example, the government should fully consider the constraints such as price rise, the elderly disability rate, and the substantial economic burden. It also can strengthen the effective combination of public LTCI and private LTCI. It does not only help to expand the space for its theoretical research but also to learn the experiences in the practice of the LTCI system in various countries around the world. It will significantly help the smooth development and further promote the in-depth reform of the LTCI system in China. [ABSTRACT FROM AUTHOR]

Background: The Chinese government has begun to dampen the growth of health expenditure by implementing Global Budgets (GB). Concerns were raised about whether reductions in expenditure would lead to a deterioration of quality of care. This paper aims to evaluate the impact of GB on health expenditure, service volume and quality of care among Chinese pneumonia patients.Methods: A secondary hospital that replaced Fee-For-Service (FFS) with GB in China in 2016 was sampled. We used daily expenditure to assess health expenditure; monthly admission, length of stay (LOS), number of drugs per record and record containing antibiotics to evaluate service volume; record with multiple antibiotics and readmission to assess quality of care. Descriptive analyses were adopted to evaluate changes after the reform, logistic regression and multivariable linear regressions were used to analyze changes associated with the reform.Results: In 2015 and 2016, 3400 admissions from 3173 inpatients and 2342 admissions from 2246 inpatients were admitted, respectively. According to regression analyses, daily expenditure, LOS, readmission, and records with multiple antibiotic usages significantly declined after the reform. However, no significant relation was observed between GB and the number of drugs per record or record containing antibiotics.Conclusions: When compared with FFS, GB can curtail health expenditure and improve quality of care. As far as service volume was concerned, LOS and monthly admission declined, while number of drugs per record and record containing antibiotics were not affected. [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: Expenditure on medications for highly prevalent chronic conditions such as diabetes mellitus (DM) can result in financial impoverishment. People in developing countries and in low socioeconomic status groups are particularly vulnerable. China and India currently hold the world's two largest DM populations. Both countries are ageing and undergoing rapid economic development, urbanisation and social change. This paper assesses the determinants of DM medication use and catastrophic expenditure on medications in older adults with DM in China and India.Methods: Using national standardised data collected from adults aged 50 years and above with DM (self-reported) in China (N = 773) and India (N = 463), multivariable logistic regression describes: 1) association between respondents' socio-demographic and health behavioural characteristics and the dependent variable, DM medication use, and 2) association between DM medication use (independent variable) and household catastrophic expenditure on medications (dependent variable) (China: N = 630; India: N = 439). The data source is the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 (2007-2010).Results: Prevalence of DM medication use was 87% in China and 71% in India. Multivariable analysis indicates that people reporting lifestyle modification were more likely to use DM medications in China (OR = 6.22) and India (OR = 8.45). Women were more likely to use DM medications in China (OR = 1.56). Respondents in poorer wealth quintiles in China were more likely to use DM medications whereas the reverse was true in India. Almost 17% of people with DM in China experienced catastrophic healthcare expenditure on medications compared with 7% in India. Diabetes medication use was not a statistically significant predictor of catastrophic healthcare expenditure on medications in either country, although the odds were 33% higher among DM medications users in China (OR = 1.33).Conclusions: The country comparison reflects major public policy differences underpinned by divergent political and ideological frameworks. The DM epidemic poses huge public health challenges for China and India. Ensuring equitable and affordable access to medications for DM is fundamental for healthy ageing cohorts, and is consistent with the global agenda for universal healthcare coverage. [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]

Objective: By analyzing the gap of hospitalization service among floating population covered by different medical insurance in Jiangsu Province, this paper aimed to understand the current situation of hospitalized health service utilization (HHSU) among floating population, and to provide policy suggestions for improving HHSU of floating population with different health insurance. Methods: The data of this study were obtained from "the National Dynamic Monitoring Survey of Floating Population in 2014". A total of 12,000 samples of floating population in Jiangsu Province were selected. 57.15% for men and 42.85% for women; 46.95% for those under 30 years old, 39.67% for 30 to 45 years old, 13.38% for over the age of forty-five. Using descriptive statistical analysis, chi-square test, exploratory factor analysis, logistic regression and stepwise multiple linear regression, the paper analyzed the difference of HHSU of floating population with different medical insurance in 2014. This study divided basic medical insurance into 3 categories: MIUE (Medical Insurance of Urban Employee), other medical insurances (including new rural cooperative medical system and the medical insurance for urban residents) and no medical insurance. Results: The hospitalization rate of floating population with MIUE (89.95%) was higher than the rate of floating population with other medical insurances (74.76%) and the gap is 15.19%. It was also higher than the rate of floating population with no medical insurance (67.57%) and the gap is 22.38%. (chi-square = 24.958, p = 0.000). 15.34% of floating population with MIUE spent more than 1600 dollars during hospitalization. It was lower than floating population with other medical insurances (16.19%) and no medical insurance (21.62%). The gaps respectively were 0.85 and 6.28% (chi-square = 10.000, p = 0.040). There existed significant differences among hospitalization medical expenses that floating population with different basic medical insurances spent. (chi-square = 225.206, p = 0.000) The type of basic medical insurance had statistical significance on whether the patients were hospitalized (p = 0.003) and whether they were hospitalized (p = 0.014). Logistic regression analysis results showed that "Social structure" (Education, Hukou, Insurance status and Work status) were significantly associated with Should be hospitalized but not and "Education" were significantly associated with Inpatient facilities selection. The stepwise multiple linear regression results presented that "Demography" and "Floating area" influenced In-hospital medical cost and "Social structure" and "Gender" influenced Reimbursement of in-hospital medical cost. Conclusion: Medical insurance type affects the hospitalization health service utilization of floating population, including Should be hospitalized but not and Reimbursement of in-hospital medical cost. [ABSTRACT FROM AUTHOR]

Background: Research on the relationships between economic development, energy consumption, environmental pollution, and human health has tended to focus on the relationships between economic growth and air pollution, energy and air pollution, or the impact of air pollution on human health. However, there has been little past research focused on all the above associations. Methods: The few studies that have examined the interconnections between the economy, energy consumption, environmental pollution and health have tended to employ regression analyses, DEA (Data Envelopment Analysis), or DEA efficiency analyses; however, as these are static analysis tools, the analyses did not fully reveal the sustainable economic, energy, environmental or health developments over time, did not consider the regional differences, and most often ignored community health factors. To go some way to filling this gap, this paper developed a modified two stage Undesirable Meta Dynamic Network model to jointly analyze energy consumption, economic growth, air pollution and health treatment data in 31 Chinese high-income and upper-middle income cities from 2013–2016, for which the overall efficiency, production efficiency, healthcare resource utilization efficiency and technology gap ratio (TGR) for all input and output variables were calculated. Results: It was found that: (1) the annual average overall efficiency in China's eastern region was the highest; (2) the production stage efficiencies were higher than the healthcare resource utilization stage efficiencies in most cities; (3) the high-income cities had lower TGRs than the upper–middle income cities; (4) the high-income cities had higher average energy consumption efficiencies than the upper-middle income cities; (5) the health expenditure efficiencies were the lowest of all inputs; (6) the high-income cities' respiratory disease and mortality rate efficiencies were higher than in the upper–middle income cities, which had improving mortality rate efficiencies; and (7) there were significant regional differences in the annual average input and output indicator efficiencies. Conclusions: First, the high-income cities had higher average efficiencies than the upper-middle income cities. Of the ten eastern region high-income cities, Guangzhou and Shanghai had average efficiencies of 1, with the least efficient being Shijiazhuang. In the other regions, the upper-middle income cities required greater technology and health treatment investments. Second, Guangzhou, Lhasa, Nanning, and Shanghai had production efficiencies of 1, and Guangzhou, Lhasa, Nanning, Shanghai and Fuzhou had healthcare resource utilization efficiencies of 1. As the average production stage efficiencies in most cities were higher than the healthcare resource utilization stage efficiencies, greater efforts are needed to improve the healthcare resource utilization. Third, the technology gap ratios (TGRs) in the high-income cities were slightly higher than in the upper-middle income cities. Therefore, the upper-middle income cities need to learn from the high-income cities to improve their general health treatment TGRs. Fourth, while the high-income cities had higher energy consumption efficiencies than the upper-middle income cities, these were decreasing in most cities. There were few respiratory disease efficiency differences between the high-income and upper-middle income cities, the high-income cities had falling mortality rate efficiencies, and the upper-middle income cities had increasing mortality rate efficiencies. Overall, therefore, most cities needed to strengthen their health governance to balance economic growth and urban expansion. Fifth, the average AQI efficiencies in both the high-income and upper-middle income cities were higher than the average CO2 efficiencies. However, the high-income cities had lower average CO2 emissions and AQI efficiencies than the upper-middle income cities, with the AQI efficiency differences between the two city groups expanding. As most cities were focusing more on air pollution controls than carbon dioxide emissions, greater efforts were needed in coordinating the air pollution and carbon dioxide emissions treatments. Therefore, the following suggestions are given. (1) The government should reform the hospital and medical systems. (2) Local governments need to strengthen their air pollution and disease education. (3) High-income cities need to improve their healthcare governance to reduce the incidence of respiratory diseases and the associated mortality. (4) Healthcare governance efficiency needs to be prioritized in 17 upper-middle income cities, such as Hangzhou, Changchun, Harbin, Chengdu, Guiyang, Kunming and Xi'an, by establishing sound medical management systems and emergency environmental pollution treatments, and by increasing capital asset medical investments. (5) Upper-middle income cities need to adapt their treatment controls to local conditions and design medium to long-term development strategies. (6) Upper-middle income cities need to actively learn from the technological and governance experiences in the more efficient higher-income cities. [ABSTRACT FROM AUTHOR]

Background: Evidences shows that socioeconomic status is reversely associated with the risk of morbidity and mortality for people with cardiovascular disease via pro-inflammation mechanism, but the population profile is not deeply defined on. We aimed to investigate the impact of medical insurance coverage on postoperative systemic inflammatory reaction in two kinds of disease populations undergoing distinct cardiac procedures.Methods: A total of 515 patients receiving open mitral valve procedure with high-total expense from May 2013 through May 2021 in Sichuan Provincial People's Hospital were retrospectively collected and stratified according to medical insurance reimbursement: low coverage with high out-pocket (< 30%), medium coverage (≤ 60%, but ≥ 30%), and high coverage (> 60%). Another 118 cases undergoing atrium septum defect (ASD) or patent foramen ovale (PFO) occlusion and taking on consistent low-total expense and low-coverage (< 30%) were also classified according to their insured conditions. The postoperative systemic inflammatory response indexes were high sensitivity C-reactive protein (hs-CRP) and the neutrophil-lymphocyte ratio (NLR).Results: Low insurance reimbursement population undergoing open mitral valve procedure had a higher level of hs-CRP and NLR but not troponin I protein or lactate within 48 h postoperatively, and higher thoracic drainage, longer ventilation use and stay in intensive care unit. No significant difference in inflammatory indexes existed among diverse medical insurance coverage in population undergoing ASD/PFO occlusion.Conclusions: Higher inflammatory reaction and weaker clinical recovery was associated with lower insurance coverage population undergoing open mitral valve procedure but not ASD/PFO interventional occlusion procedure. [ABSTRACT FROM AUTHOR]

Background: To improve access to outpatient services and provide financial support in outpatient expenses for the insured, China has been establishing its scheme of decreasing the out-of-pocket expenses for outpatient care in recent years. There are 156 million diabetes patients in China which almost accounts for a quarter of diabetes population worldwide. Outpatient services plays an important role in diabetes treatment. The study aims to clarify the effects of decreasing the out-of-pocket expenses for outpatient care on health-seeking behaviors, health outcomes and medical expenses of people with diabetes. Methods: This study constructed a two-way fixed effect model, utilized 5,996 diabetes patients' medical visits records from 2019 to 2021, to ascertain the influence of decreasing the out-of-pocket expenses for outpatient care on diabetes patients. The dependent variables were diabetes patients' health-seeking behaviors, health outcomes, medical expenses and expenditure of the basic medical insurance funds for them; the core explanatory variable was the out-of-pocket expenses for outpatient care expressed by the annual outpatient reimbursement ratio. Results: With each increase of 1% in the annual outpatient reimbursement ratio: (1) for health-seeking behaviors, a diabetes patient's annual number of outpatient visits and annual number of medical visits increased by 0.021 and 0.014, while the annual number of hospitalizations decreased by 0.006; (2) for health outcomes, a diabetes patient's annual length of hospital stays and average length of a hospital stay decreased by 1.2% and 1.1% respectively, and the number of diabetes complications and Diabetes Complications Severity Index (DCSI) score both decreased by 0.001; (3) for medical expenses, a diabetes patient's annual outpatient expenses, annual inpatient expenses, annual medical expenses and annual out-of-pocket expenses decreased by 2.2%, 4.6%, 2.6% and 4.0%; (4) for expenditure of the basic medical insurance funds for a diabetes patient, the annual expenditure on outpatient services increased by 1.1%, and on inpatient services decreased by 4.4%, but on healthcare services didn't change. Conclusion: Decreasing the out-of-pocket expenses for outpatient care appropriately among people with diabetes could make patients have a more rational health-seeking behaviors, a better health status and a more reasonable medical expenses while the expenditure of the basic medical insurance funds is stable totally. [ABSTRACT FROM AUTHOR]

Background: Illness is the leading cause (44%) of poverty in China. Since 2016, The health poverty alleviation project, an integral component of the Targeted Poverty Alleviation in China, was implemented in 2016 to strengthen financial risk protection against illness for financially backward segments of the population. However, the effects of the health poverty alleviation project on financial risk protection have not been explored in the literature, this paper aims to bridge the gap. Methods: Using panel data on 63,426 rural households in Chishui City, China, from 2014 to 2017, the difference-in-differences with propensity score matching method was employed. Results: The health poverty alleviation project reduces out-of-pocket payments by 15% on average and decreases the probability of catastrophic health expenditure (annual out-of-pocket payments exceeding 10% of annual household income) and impoverishing health spending occurrence (out-of-pocket payments are forcing a household into poverty or into deeper poverty) by 7.7 and 11.7%, respectively. Additionally, the project increases the number of annual hospitalizations per household by 0.035. Conclusion: Our study demonstrates that the health poverty alleviation project significantly improves financial risk protection by reducing out-of-pocket payments and decreasing the probability of incurring catastrophic or impoverishing levels of health expenditure. Our study has implications for the poverty reduction policies and reform of the Chinese health financing system. [ABSTRACT FROM AUTHOR]

Background: Since 2015, all pilot cities of public hospital reform in China have allowed the zero-markup drug policy and implemented the policy of Separating of Hospital Revenue from Drug Sales (SHRDS). The objective of this study is to evaluate whether SHRDS policy reduces the burden on patients, and to identify the mechanism through which SHRDS policy affects healthcare expenditure. Methods: In this study, we use large sample data of urban employee's healthcare insurance in Chengdu, and adopt the difference in difference model (DID) to estimate the impact of the SHRDS policy on total healthcare expenditures and drug expenditure of patients, and to provide empirical evidence for deepening medical and health system reform in China. Results: After the SHRDS policy's implementation, the total healthcare expenditure kept growing, but the growth rate slowed down between 2014 to 2015. The total healthcare expenditure of patients decreased by only 0.6%, the actual reimbursement expenditure of patients decreased by 4.1%, the reimbursement ratio decreased by 2.6%. and the drugs expenditure dropped by 14.4%. However, the examinations expenditure increased by 18.2%, material expenditure increased significantly by 38.5%, and nursing expenditure increased by 12.7%. Conclusions: After implementing the SHRDS policy, the significant reduction in drug expenditure led to more physicians inducing patients' healthcare service needs, and the increased social healthcare burden was partially transferred to the patients' personal economic burden through the decline in the reimbursement ratio. The SHRDS policy is not an effective way to control healthcare expenditure. [ABSTRACT FROM AUTHOR]

Background: Cancer imposes substantial burdens on cancer suffers, their families and the health system, especially in the end of life (EOL) of care patients. There are few developing country studies of EOL health care costs and no specialist studies of the disparities in cancer treatment and care costs by geographical location in China. We sought to examine geographical disparities in the types of cancer treatments and care costs during the last 3 months of life for Chinese cancer patients.Methods: Using snowball sampling and face-to-face interviews, field research was conducted with a specialist questionnaire. Data were collected on 792 cancer patients who died between July 2013 and June 2016 in China. Total EOL health care costs were modeled using generalized linear models (GLMs) with log link and gamma distribution.Results: Total health care costs were highest for urban (US$12,501) and western region (US$9808) patients and lowest for rural (US$5996) and central region (US$5814) patients. Our study revealed about 40% of the health care expenses occur in the last three months of life, and was mainly driven by hospital costs that accounted for about 70% of EOL expenditures. Patients faced out-of-pocket expenses for health care, with the ability to borrow from family and friends also impacting the type of treatment and health facility. Life-extending treatments per cancer patient was about two times that of patients receiving conservative treatments.Urban patients were more likely to receive life-extending treatments, financed by higher incomes and a greater capacity to borrow from family and friends to bridge the gap between health insurance reimbursements and out-of-pocket expenditures. Cancer patients in western region and urban area were significantly more likely to access hospice care.Conclusions: We found significant urban-rural and regional disparities in EOL types of cancer treatment, utilization of medical care and the health care expenditures. The EOL cancer care costs imposed heavy economic burdens in China.We recommend better clinical guidelines, improved EOL conversations and fuller information on treatment regimes among patients, family caregivers and doctors. Policies and information should pay more attention to palliative care options and the socio-cultural context of cancer care decision-making by family. [ABSTRACT FROM AUTHOR]

Background: With rapid economy growth, the prevalence of obesity, and related chronic diseases, has increased greatly. Although this has been widely recognized, little attention has been paid to the influence of built environment and economic growth, particularly for developing countries. The main purpose of this study is to investigate the potential relationship between the prevalence of diabetes and the built environment while considering the effects of socioeconomic change in China. Methods: Three nationally representative samples are constructed and employed mainly based on various sources of data, such as the China National Nutrition and Health Survey, World Health Organization, and China Health and Retirement Longitudinal Survey in 2013. The explanatory variables representing the built environment and influential factors include the health outcomes, economic indicators, local health facilities, regional dummies, and demographic features. OLS, robust regressions, and a set of binary choice models are used to estimate the possible relationship. Results: It is suggested that the prevalence of diabetes is associated with both the broader built environment and individual economic factors in China. China's sharp economic growth in the recent decades has greatly increased the prevalence of obesity and diabetes, when also considering other influential factors. Conclusions: Although the results can not specify causal mechanism, some useful results can be clearly discovered and subsequently a few important policy implications can be provided for the sustainable and healthy development of China's urban planning or built environment. [ABSTRACT FROM AUTHOR]

Background: Catastrophic health expenditure (CHE) puts a heavy disease burden on patients' families, aggravating income-related inequality. In an attempt to reduce the financial risks of rural families incurring CHE, China began the New Rural Cooperative Medical System (NCMS) on a trial basis in 2003 and has raised the reimbursement rates continuously since then. Based on statistical data about rural families in sample area of Jiangsu province, this study measures the incidence of CHE, analyzes socioeconomic inequality related to CHE, and explores the influences of the NCMS on the incidence of CHE.Methods: Statistical data were acquired from two surveys about rural health care, one conducted in 2009 and one conducted in 2010. In 2009, 1424 rural families were analyzed; in 2010, 1796 rural families were analyzed. An index of CHE is created to enable the evaluation of the associated financial risks. The concentration index and concentration curve are used to measure the income-related inequality involved in CHE. Multiple logistic regression is utilized to explore the factors that influence the incidence of CHE.Results: The incidence of CHE decreased from 13.62% in 2009 to 7.74% in 2010. The concentration index of CHE was changed from -0.298 (2009) to -0.323 (2010). Compared with rural families in which all members were covered by the NCMS, rural families in which some members were not covered by the NCMS had a lower incidence of CHE: The odds ratio is 0.65 with a 95% confidence interval of 0.43 to 1.00. For rural families in which all members were covered by the NCMS, the increase in reimbursement rates is correlated to the decline in the incidence of CHE if other influencing factors were controlled: The odds ratio is 0.48 with a 95% confidence interval of 0.36 to 0.64.Conclusions: Between 2009 and 2010, the incidence rate of CHE in the sampled area decreased sharply, CHE was more concentrated among least wealthy and inequality increased during study period. As of 2010, the poorest rural families still had high risk of experiencing CHE. For rural families in which all members are covered by the NCMS, the rise in reimbursement rates reduces the probability of experiencing CHE. [ABSTRACT FROM AUTHOR]

Background: Obesity is a serious public health problem in China. The relationship between obesity and socio-economic status (SES) is changing and affected by uncertainty, particularly, in developing countries. The sex-related differences in body mass index (BMI) trajectories are controversial and require substantial empirical data for updating and enriching. Methods: This study examined the relationship between SES and BMI in Chinese adults from a dynamic perspective using longitudinal data (1991-2011) from the China Health and Nutrition Survey (CHNS). Then, sex-related differences were determined. A hierarchical linear model was used. Results: SES positively affected the male BMI changes, with faster BMI growth rates in the high-SES males over the past 20 years. By contrast, female BMI was only affected by BMI baseline and residential area. Specifically, greater BMI baseline led to greater BMI growth rate and earlier BMI decline. In the past 20 years, the BMI growth rate has been greater in the urban females than in the rural females. Conclusions: The relationship between SES and obesity is complex in China, and a substantial sex-related difference exists. We argue that this large sex-related difference is due to the rapid economic and social changes that have affected national health and increased the gender inequality and social role restrictions in females. We provide insights for further research and policy recommendations. [ABSTRACT FROM AUTHOR]

Background: China has a high prevalence of human papillomavirus (HPV) and a consequently high burden of disease with respect to cervical cancer. The HPV vaccine has proved to be effective in preventing cervical cancer and is now a part of routine immunization programs worldwide. It has also proved to be cost effective. This study aimed to assess the cost-effectiveness of 2-, 4-, and 9-valent HPV vaccines (hereafter, HPV2, 4 or 9) combined with current screening strategies in China.Methods: A Markov model was developed for a cohort of 100,000 HPV-free girls to simulate the natural history to HPV infection. Three recommended screening methods (1. liquid-based cytology test + HPV DNA test; 2. pap smear cytology test + HPV DNA test; 3. visual inspection with acetic acid) and three types of HPV vaccination program (HPV2/4/9) were incorporated into 15 intervention options, and the incremental cost-effectiveness ratio (ICER) was calculated to determine the dominant strategies. Costs, transition probabilities and utilities were obtained from a review of the literature and national databases. One-way sensitivity analyses and threshold analyses were performed for key variables in different vaccination scenarios.Results: HPV9 combined with screening showed the highest health impact in terms of reducing HPV-related diseases and increasing the number of quality-adjusted life years (QALYs). Under the current thresholds of willingness to pay (WTP, 3 times the per capita GDP or USD$ 23,880), HPV4/9 proved highly cost effective, while HPV2 combined with screening cost more and was less cost effective. Only when screening coverage increased to 60% ~ 70% did the HPV2 and screening combination strategy become economically feasible.Conclusions: The combination of the HPV4/9 vaccine with current screening strategies for adolescent girls was highly cost-effective and had a significant impact on reducing the HPV infection-related disease burden in Mainland China. [ABSTRACT FROM AUTHOR]

Background: China has been undergoing tremendous demographic and epidemiological transitions during the past three decades and increasing burden from non-communicable diseases and an ageing population have presented great health-care challenges for the country. Numerous studies examine catastrophic healthcare expenditures (CHE) worldwide on whole populations rather than specific vulnerable groups. As hypertension and other chronic conditions impose a growing share of the disease burden in China, they will become an increasingly important component of CHE. This study aims to estimate households with hypertension incurring CHE and its income-related inequality in the rural areas of Shaanxi Province. Methods: Data were obtained from the National Household Health Service Surveys of Shaanxi Province conducted in 2013 and 13104 households were identified for analysis. The households were classified into three types: households with non-chronic diseases, households with hypertension only and households with hypertension plus other chronic diseases. CHE was measured according to the proportion of out-of-pocket health payments to non-food household expenditures and the concentration index was employed to measure the extent of income-related inequality in CHE. A decomposition method based on a probit model was used to decompose the concentration index into its determining components. Results: The incurring of CHE of households with hypertension is at a disconcerting level compared to households with non-chronic diseases. Households with hypertension only and households with hypertension plus other chronic diseases incurred CHE in 23.48% and 34.01% of cases respectively whereas households with non-chronic diseases incurred CHE in only 13.33%. The concentration index of households with non-chronic diseases is -0.4871. However, the concentration index of households with hypertension only and households with hypertension plus other chronic diseases is -0.4645 and -0.3410 respectively. The majority of observed inequalities in CHE were explained by household economic status and having elder members. Conclusions: The proportion of households incurring CHE in the rural areas of Shaanxi Province was considerably high in all three types of households and households with hypertension were at a higher risk of incurring CHE. Furthermore, there existed a strong pro-poor inequality of CHE in all three types of households and the results implied more inequality in households with non-chronic diseases compared with two other groups. Our study suggests that more concern needs to be directed toward households with hypertension plus other chronic diseases and households having elder members. [ABSTRACT FROM AUTHOR]

Background: While the demand for the health service keeps escalating at the grass root or rural areas of China, a substantial portion of healthcare resources remains stagnant in the more developed cities and this has entrenched health inequity in many parts of China. At its conception, the Deepening Health Care Reform in 2012 China was intended to flush out these discrepancies and promote a more equitable and efficient distribution of health resources. Nearly half a decade of this reform, there are uncertainties as to whether the attainment of the objectives of the reform is in sight. Methods: We divided Jiangsu Province into 3 zones according to the level of economic and social development i.e. developed, developing, and undeveloped areas. Using a hybrid of Panel data analysis and an augmented Data Envelopment Analysis (DEA), we model human resources, capital inputs of Community Health Centers to comprehensively determine the technical and scale efficiency of community health resources in 3 zones in Jiangsu Province. Results: We sampled data and analysed efficiency and productivity growth of 75 Community Health Centers in 13 cities of Jiangsu Province from 2011 to 2015, which shows that a significant productive growth among Community Health Centers between 2011 and 2015. Mirroring the behavior of Community Health Centers, technological progress was the underlying force for the growth and the deterioration in efficiency change was found. This can be credited partly to the Deepening Health Care Reform measures aimed at improving technology availability in health centers in sub-urban areas. The regional summary of the DEA result shows that the stage of economic development and the efficiency performance of hospital did not necessarily go hand in hand among the 3 zones of Jiangsu. Conclusions: The government of China in general and Jiangsu province in particular could improve the efficiency of health resources allocation by improving the community health service system, rationalizing the allocation of health personnel, optimizing the allocation of material resources and enhancing the level of health of financial resources allocation. [ABSTRACT FROM AUTHOR]

Background: Systems of governance play a key role in the operation and performance of health systems. In the past six decades, China has made great advances in strengthening its health system, most notably in establishing a health insurance system that enables residents of rural areas to achieve access to essential services. Although there have been several studies of rural health insurance schemes, these have focused on coverage and service utilization, while much less attention has been given to the role of governance in designing and implementing these schemes. Methods: Information from publications and policy documents relevant to the development of two rural health insurance policies in China was obtained, analysed, and synthesise. 92 documents on CMS (Cooperative Medical Scheme) or NCMS (New Rural Cooperative Medical Scheme) from four databases searched were included. Data extraction and synthesis of the information were guided by a framework that drew on that developed by the WHO to describe health system governance and leadership. Results: We identified a series of governance practices that were supportive of progress, including the prioritisation by the central government of health system development and certain health policies within overall national development; strong government commitment combined with a hierarchal administrative system; clear policy goals coupled with the ability for local government to adopt policy measures that take account of local conditions; and the accumulation and use of the evidence generated from local practices. However these good practices were not seen in all governance domains. For example, poor collaboration between different government departments was shown to be a considerable challenge that undermined the operation of the insurance schemes. Conclusions: China's success in achieving scale up of CMS and NCMS has attracted considerable interest in many low and middle income countries (LMICs), especially with regard to the schemes' designs, coverage, and funding mechanisms. However, this study demonstrates that health systems governance may be critical to enable the development and operation of such schemes. Given that many LMICs are expanding health financing system to cover populations in rural areas or the informal sectors, we argue that strengthening specific practices in each governance domain could inform the adaptation of these schemes to other settings. [ABSTRACT FROM AUTHOR]

Background: Global healthcare innovation networks nowadays have expanded beyond developed countries with many developing countries joining the force and becoming important players. China, in particular, has seen a significant increase in the number of innovative firms and research organizations stepping up to the global network in recent years. Nevertheless, the intense Research and Development input has not brought about the expectable output. While China is ascending at a great speed to a leading position worldwide in terms of Research and Development investment, scientific publications and patents, the innovation capabilities in the pharmaceutical sector remain weak.Discussion: This study discusses the challenges and opportunities for pharmaceutical innovation in China. One hand, academic, industrial, institutional and financial constraints were found to be the major and inevitable barriers hindering the development of drug innovation. On the other hand, unique advantages had been observed which included growing pharmaceutical market, Research and Development funding, distinctive source, and international cooperation. The most important thing for China's pharmaceutical sector to leap forward is to break though innovation barriers and integrate own advantages into global value-chain of healthcare product development. [ABSTRACT FROM AUTHOR]

Background: In past two decades, health expenditure in China grew at a rate of 11.6% per year, which is much faster than the growth of the country's economy (9.9% per year). As cost containment is a key aspect of China's new health system reform agenda, this study aims to identify the main drivers of past growth so that cost containment policies are focussed in the right areas.Method: The analysis covered the period 1993-2012. To understand the drivers of past growth during this period, Das Gupta's decomposition method was used to decompose the changes in health expenditure by disease into five main components that include population growth, population ageing, disease prevalence rate, expenditure per case of disease, and excess health price inflation. Demographic data on population size and age-composition were obtained from the Department of Economic and Social Affairs of the United Nations. Age- and disease- specific expenditure and prevalence rates by age and disease were extracted from China's National Health Accounts studies and Global Burden of Disease 2013 studies of the Institute for Health Metrics and Evaluation, respectively.Results: Growth in health expenditure in China was mainly driven by a rapid increase in real expenditure per prevalent case, which contributed 8.4 percentage points of the 11.6% annual average growth. Excess health price inflation and population growth contributed 1.3 and 1.3% respectively. The effect of population ageing was relatively small, contributing 0.8% per year. However, reductions in disease prevalence rates reduced the growth rate by 0.3 percentage points.Conclusion: Future policy in optimising growth in health expenditure in China should address growth in expenditure per prevalent case. This is especially so for neoplasms, and for circulatory and respiratory disease. And a focus on effective interventions to reduce the prevalence of disease in the country will ensure that changing disease rates do not lead to a higher growth in future health expenditure; Measures should be taken to strengthen the capacity of health personnel in grass-roots facilities and to establish an effective referral system, so as to reduce the growth in expenditure per case of disease and to ensure that excess health price inflation does not grow out of control. [ABSTRACT FROM AUTHOR]

Background: Screening is the main preventive method for cervical cancer in developing countries, but each type of screening has advantages and disadvantages. To investigate the most suitable method for low-income areas in China, we conducted a health economic analysis comparing three methods: visual inspection with acetic acid and Lugol's iodine (VIA/VILI), ThinPrep cytology test (TCT), and human papillomavirus (HPV) test.Methods: We recruited 3086 women aged 35-65 years using cluster random sampling. Each participant was randomly assigned to one of three cervical cancer screening groups: VIA/VILI, TCT, or HPV test. In order to calculate the number of disability-adjusted life years (DALYs) averted by each screening method, we used Markov models to estimate the natural development of cervical cancer over a 15-year period to estimate the age of onset and duration of each disease stage. The cost-effectiveness ratios (CERs), net present values (NPVs), benefit-cost ratios (BCRs), and cost-utility ratios (CURs) were used as outcomes in the health economic analysis.Results: The positive detection rate in the VIA/VILI group was 1.39%, which was 4.6 and 2.0 times higher than the rates in the TCT and HPV test groups, respectively. The positive predictive value of VIA/VILI (10.53%) was highest while the rate of referral for colposcopy was lowest for those in the HPV + TCT group (0.60%). VIA/VILI performed the best in terms of health economic evaluation results, as the cost of per positive case detected was 8467.9 RMB, which was 24503.0 RMB lower than that for TCT and 5755.9 RMB lower than that for the HPV test. In addition, the NPV and BCR values were 258011.5 RMB and 3.18 (the highest), and the CUR was 2341.8 RMB (the lowest). The TCT performed the worst, since its NPV was <0 and the BCR was <1, indicative of being poorly cost-beneficial.Conclusions: With the best economic evaluation results and requiring minimum medical resources, VIA/VILI is recommended for cervical cancer screening in poverty-stricken areas in China with high incidence of cervical cancer and lack of medical resources. [ABSTRACT FROM AUTHOR]

Background: Although many studies have investigated the relationship between the introduction of the New Cooperative Medical Scheme (NCMS) in rural China in 2003 and increased use of medical services, the effect on health status, objectively measured, is seldom reported. In Anhui Province a chronic disease scheme (CDS) for reimbursing part of the cost of outpatient care is designed to improve management of those with chronic conditions, including diabetes.Methods: A follow-up study was designed in which patients with diabetes aged 40-70 years who had recently (in 2010) been granted a chronic disease card were individually matched on age, sex and village with a patient with diabetes not yet in the scheme. Each subject gave a fingertip sample of blood to give the concentration of glycosylated hemoglobin (HbA1c), a measure indicating blood glucose control during the previous 3 months. This measure was made on recruitment and at 12 month follow-up: information on use of health services, quality of life and financial burden was also collected at the two contacts.Results: Of 602 pairs initially recruited, 528 pairs were contacted at follow-up and are the subject of this report. To distinguish between outcomes associated with application and those of membership of the scheme, the primary analysis was of 256 pairs in which one had been a member of the CDS throughout and the other never applied. No difference between pairs on HbA1c was found either at recruitment or follow-up but those in the CDS reported more hospital visits, more tests and more use of high level hospitals. However they had poorer scores on quality of life scales (SF-12, EQ-5D) and were more likely to report that the financial costs were very burdensome. Those recently applying for the scheme, or being accepted since recruitment, had lower HbA1c scores.Conclusions: On-going membership of the CDS was associated with increased use of services but this did not appear to result in better management of blood glucose or improved quality of life. Those who had recently joined the scheme had signs of improvement, suggesting a need for active follow-up to maintain and reinforce early gains. [ABSTRACT FROM AUTHOR]

Background: The New Cooperative Medical Scheme (NCMS) in rural China has been expanding in both population coverage and benefit package. China has also established an essential medicine policy in recent years to further reduce patients' medical expenditures and financial burden. This study aims to evaluate the impact of these policies on reducing medical expenditures and financial burden of patients diagnosed with hypertension and diabetes.Methods: This study used repeated cross-sectional surveys in 2011 and 2012 in three counties of Shandong Province. Outpatient and inpatient service expenditures and catastrophic health expenditures (CHE) were measured and analyzed.Results: Medical expenditures for outpatient services significantly increased for hypertensive and diabetic patients within a 1 year period, while inpatient service expenditures remained unchanged. Although NCMS increased its reimbursement rate, hypertensive and diabetic patients still heavily suffered CHE from both outpatient and inpatient services. Outpatient services were more important factors than inpatient services contributing to non-communicable chronic diseases (NCD) patients' financial burden.Conclusions: The effects of NCMS expansion have been offset by the rapid escalation of medical expenditures. More attention should be paid to the design of NCMS benefit package to cover NCD outpatient services. There is also an urgent need to reform the current Fee for Service to other provider payment methods in order to control the escalating NCD medical expenditures. [ABSTRACT FROM AUTHOR]

Background: The disparity between government health expenditures across regions is more severe in developing countries than it is in developed countries. The capitation subsidy method has been proven effective in developed countries in reducing this disparity, but it has not been tested in China, the world's largest developing country.Methods: The convergence method of neoclassical economics was adopted to test the convergence of China's regional government health expenditure. Data were obtained from Provinces, Prefectures and Counties Fiscal Statistical Yearbook (2003-2007) edited by the Chinese Ministry of Finance, and published by the Chinese Finance & Economics Publishing House.Results: The existence of σ-convergence and long-term and short-term β-convergence indicated the effectiveness of the capitation subsidy method in the New Rural Cooperative Medical Scheme on narrowing county government health expenditure disparities. The supply-side variables contributed the most to the county government health expenditure convergence, and factors contributing to convergence of county government health expenditures per capita were different in three regions.Conclusion: The narrowing disparity between county government health expenditures across regions supports the effectiveness of the capitation subsidy method adopted by China's New Rural Cooperative Scheme. However, subsidy policy still requires further improvement. [ABSTRACT FROM AUTHOR]

Background: China has become the world's second largest healthcare market based on a recent report by the World Health Organization. Eventhough China achieved universal health insurance coverage in 2011, representing the largest expansion of insurance coverage in human history achieved; health inequality remains endemic in China. Lessons from the effect of market crisis on health equity in Europe and other places has reignited interest in exploring the potential healthcare market aberrations that can trigger distributive injustice in healthcare resource allocation among China's provinces. Recently, many healthcare investors in China have become more concerned about capital preservation, and are responding by abandoning long term investments strategies in healthcare. This investment withdrawal en mass is perceived to be influenced by herding tendencies and can trigger or consolidate endemic health inequality. Methods: Our study simultaneously employs four testing models (two state spaced models and two return dispersion models) to establish the existence of procyclical (herding) behavior among the stocks and its health equity implications. These are applied to a large set of data to compare and contrast results of herd formation among investors in fourteen healthcare sectors in China. Results: The study reveals that apart from the cross sectional standard deviation (CSSD) model, the remaining two models and our augmented state space model yields significant evidence of herding in all subsectors of the healthcare market. We also find that the herding effect is more prominent during down movements of the market. Conclusion: Herding behavior may lead to contemporaneous loss of investor confidence and capital withdrawal and thereby deprive the healthcare sector of the much needed capital for expansion. Thus there may be obvious delay in efforts to bridge the gap in access to healthcare facilities, medical support services, medical supplies, pharmaceuticals, biotechnology, diagnostic substances, medical laboratory and advanced medical equipment across China. Moreover, a potential crash in the healthcare market is possible in the healthcare sector as a result of persistent herding tendencies among investors and that may have more damaging consequences for health inequality in China. [ABSTRACT FROM AUTHOR]

Background: China is actively promoting regulation of rare diseases, rare disease and orphan drugs have been formally incorporated into the national planning. However, few studies have been done to evaluate the affordability of rare disease patients in China. This study aims to provide policy recommendations for the establishment of social security mechanism for rare diseases in China, so as to address the problem of poverty caused by these diseases.Methods: A total of 7 rare diseases were selected by Delphi method. Affordability of treatment for the 7 rare diseases was assessed through annual per capital income, catastrophic expenditure and impoverishment expenditure among urban and rural residents in China.Results: Assessed through annual per capital income, health expenditure for the 7 rare diseases are all rather high. The highest health expenditure is equivalent to income of 69.34 years of one urban resident, and the burden is heavier for rural residents. Through catastrophic expenditure assessment, proportions of the population experiencing catastrophic expenditure caused by the 7 rare diseases are all under 0.167 ‰. However, once one is ill and taking medications, he will suffer from catastrophic health expenditure. Through impoverishment expenditure assessment, the proportions of impoverishment payment are low among both urban and rural residents, but the 7 rare diseases could lead nearly 4.6 million people into poverty on a national scale.Conclusion: The affordability of treatment for rare disease as well as orphan drugs is rather poor. Residents of different income levels all have difficulties to afford the treatment for rare diseases, so poverty caused by rare diseases is quite widespread. Therefore, social security mechanism for rare disease patients should be established and specific payment pattern for orphan drugs should be set up. [ABSTRACT FROM AUTHOR]

Background: Lifestyle and dietary changes reflect an ongoing epidemiological transition in China, with cardiovascular disease (CVD) playing an ever-increasing role in China's disease burden. This study assessed the burden of CVD and the potential value of lipid and blood pressure control strategies in China.Methods: We estimated the likely burden of CVD between 2016 and 2030 and how expanded use of lipid lowering and blood pressure control medication would impact that burden in the next 15 years. Accounting for the costs of drug use, we assessed the net social value of a policy that expands the utilization of lipid and blood pressure lowering therapies in China.Results: Rises in prevalence of CVD risk and population aging would likely increase the incidence of acute myocardial infarctions (AMIs) by 75 million and strokes by 118 million, while the number of CVD deaths would rise by 39 million in total between 2016 and 2030. Universal treatment of hypertension and dyslipidemia patients with lipid and blood pressure lowering therapies could avert between 10 and 20 million AMIs, between 8 and 30 million strokes, and between 3 and 10 million CVD deaths during the 2016-2030 period, producing a positive social value net of health care costs as high as $932 billion.Conclusions: In light of its aging population and epidemiological transition, China faces near-certain increases in CVD morbidity and mortality. Preventative measures such as effective lipid and blood pressure management may reduce CVD burden substantially and provide large social value. While the Chinese government is implementing more systematic approaches to health care delivery, prevention of CVD should be high on the agenda. [ABSTRACT FROM AUTHOR]

Background: Against the achievement of nearly universal coverage for social health insurance for the elderly in China, a problem of inequity among different insurance schemes on health outcomes is still a big challenge for the health care system. Whether various health insurance schemes have divergent effects on health outcome is still a puzzle. Empirical evidence will be investigated in this study.Methods: This study employs a nationally representative survey database, the National Survey of the Aged Population in Urban/Rural China, to compare the changes of health outcomes among the elderly before and after the reform. A one-way ANOVA is utilized to detect disparities in health care expenditures and health status among different health insurance schemes. Multiple Linear Regression is applied later to examine the further effects of different insurance plans on health outcomes while controlling for other social determinants.Results: The one-way ANOVA result illustrates that although the gaps in insurance reimbursements between the Urban Employee Basic Medical Insurance (UEBMI) and the other schemes, the New Rural Cooperative Medical Scheme (NCMS) and Urban Residents Basic Medical Insurance (URBMI) decreased, out-of-pocket spending accounts for a larger proportion of total health care expenditures, and the disparities among different insurances enlarged. Results of the Multiple Linear Regression suggest that UEBMI participants have better self-reported health status, physical functions and psychological wellbeing than URBMI and NCMS participants, and those uninsured. URBMI participants report better self-reported health than NCMS ones and uninsured people, while having worse psychological wellbeing compared with their NCMS counterparts.Conclusions: This research contributes to a transformation in health insurance studies from an emphasis on the opportunity-oriented health equity measured by coverage and healthcare accessibility to concern with outcome-based equity composed of health expenditure and health status. The results indicate that fragmented health insurance schemes generate inequitable health care utilization and health outcomes for the elderly. This study re-emphasizes the importance of reforming health insurance systems based on their health outcome rather than entitlement, which will particularly benefit the most vulnerable older groups. [ABSTRACT FROM AUTHOR]

Background: Syndromic surveillance systems (SSSs) collect non-specific syndromes in early stages of disease outbreaks. This makes an SSS a promising tool for the early detection of epidemics. An Integrated Surveillance System in rural China (ISSC project), which added an SSS to the existing Chinese surveillance system for the early warning of epidemics, was implemented from April 2012 to March 2014 in Jiangxi and Hubei Provinces. This study aims to measure the costs and effectiveness of the three components of the SSS in the ISSC project.Methods: The central measures of the cost-effectiveness analysis of the three components of the syndromic surveillance system were: 1) the costs per reported event, respectively, at the health facilities, the primary schools and the pharmacies; and 2) the operating costs per surveillance unit per year, respectively, at the health facilities, the primary schools and the pharmacies. Effectiveness was expressed by reporting outputs which were numbers of reported events, numbers of raw signals, and numbers of verified signals. The reported events were tracked through an internal data base. Signal verification forms and epidemiological investigation reports were collected from local country centers for disease control and prevention. We adopted project managers' perspective for the cost analysis. Total costs included set-up costs (system development and training) and operating costs (data collection, quality control and signal verification). We used self-designed questionnaires to collect cost data and received, respectively, 369 and 477 facility and staff questionnaires through a cross-sectional survey with a purposive sampling following the ISSC project. All data were entered into Epidata 3.02 and exported to Stata for descriptive analysis.Results: The number of daily reported events per unit was the highest at pharmacies, followed by health facilities and finally primary schools. Variances existed within the three groups and also between Jiangxi and Hubei. During a 15-month surveillance period, the number of raw signals for early warning in Jiangxi province (n = 36) was nine times of that in Hubei. Health facilities and primary schools had equal numbers of raw signals (n = 19), which was 9.5 times of that from pharmacies. Five signals were confirmed as outbreaks, of which two were influenza, two were chicken pox and one was mumps. The cost per reported event was the highest at primary schools, followed by health facilities and then pharmacies. The annual operating cost per surveillance unit was the highest at pharmacies, followed by health facilities and finally primary schools. Both the cost per reported event and the annual operating cost per surveillance unit in Jiangxi in each of the three groups were higher than their counterparts in Hubei.Conclusions: Health facilities and primary schools are better sources of syndromic surveillance data in the early warning of outbreaks. The annual operating costs of all the three components of the syndromic surveillance system in the ISSC Project were low compared to general government expenditures on health and average individual income in rural China. [ABSTRACT FROM AUTHOR]

Background Although numerous studies examine catastrophic health expenditures (CHE) worldwide, most focus on whole populations rather than specific vulnerable groups. This study analyzes the extent, associated factors and inequality of CHE in elderly household with chronic disease patients in China. Methods Data were obtained from a nationally representative elderly household survey--the China Health and Retirement Longitudinal Study--that was conducted by the National School of Development of Peking University in 2011. An elderly household with chronic disease patients is defined by = 1 chronic disease patient who is = 45 years of age. CHE was measured according to the proportion of out-of-pocket health payments to non-food household expenditures. The associated factors of CHE were estimated using ordinary least square and logistic regression modeling. CHE inequality was measured according to the concentration index (CI) and its decomposition. Results CHE incidence and intensity were relatively high among elderly households with chronic disease patients. The main associated factors of CHE include household size, having members > 65 years, having members with ≥ 2 chronic diseases, per capita income, and elderly household members demonstrating healthcare-seeking behaviors. Healthcare insurance did not significantly affect CHE risk. Disproportionate concentration of CHE was noted among elderly households, and poor elderly households demonstrated a higher probability of experiencing CHE. Factors such as household size, per capita income, having members > 65 years, and having members with ≥ 2 chronic diseases are major and positive contributors to CHE inequality. Some inpatient and outpatient services are negatively contributed to CHE inequality,suggesting that the unequal usage of such services reduces CHE inequality among elderly households with chronic disease patients. Conclusion Policy efforts should focus on improving financial protection and relieving the economic burden of disease in elderly households. The government should increase income subsidies and optimize social health insurance programs, thereby reducing CHE and alleviating CHE inequality among elderly households in China. [ABSTRACT FROM AUTHOR]

Introduction This study assessed income--related health inequality and health achievement in children in China, and additionally, examined province-level variations in health achievement. Methods Longitudinal data on 19,801 children under 18 years of age were derived from the China Health and Nutrition Survey. Income--related health inequality and health achievement were measured by the Health Concentration and Health Achievement Indices, respectively. Panel data with a fixed effect multiple regression model was employed to examine province-level variations in health achievement. Results A growing trend was towards greater health inequality among Chinese children over the last two decades. Although health achievement was getting better over time, the pro-rich inequality component has lessened the associated gain in achievement. Health achievement was positively impacted by middle school enrollments, the urbanization rate, inflation-adjusted per capita gross domestic product, and per capita public health spending. Conclusion This study has provided evidence that average health status of Chinese children has improved, but inequality has widened. Widening inequality slowed the growth in health achievement for children over time. There were wide variations in health achievement throughout China. [ABSTRACT FROM AUTHOR]

Context: Reliable estimates of wood density (WD) within individual trees could maximize the value of Pinus massoniana for specific end-use. Aim: We examined and quantified the axial patterns of WD in trees with different social status in the stands. Methods: Wood disks were sampled at the bottom, breast height, and middle of each 1-m sections from 108 stems, harvesting from three social classes in subtropical forests. A mixed-effects model was designed to quantify axial variation. Results: The WD at different height was significantly different from the whole-stem WD (WWD) except the relative height of 0.1. An overall decrease of 133.8 kg m in WD was found from stem base to top. WD was significantly influenced by relative heights, tree age, and social class. WD of each relative height in mature trees was significantly higher than that of younger trees. Tree social class can affect WD development in the axial direction at age classes 2 and 3. Combining the fixed plus random effects, the final model explained 91 % of the observed variation in WD. Conclusion: The WD development patterns in the axial direction vary considerably among tree age, diameter at breast height, and social class. To distinguish and supply timber for specific end-uses, we should use the axial variation in disk WD (DWD) instead of WWD directly. The accurate predictions of WD provided by the model could be used to optimally classify logs into different product classes and maximize economic benefits. We can use DWD at the relative height of 0.1 instead of WWD of a single tree. [ABSTRACT FROM AUTHOR]

Background: Cancer is the second leading cause of death globally, causing a substantial economic burden on cancer suffers and their families. The aim of this study is to explore the prevalence, determinants and consequences of catastrophic health expenditure (CHE) among urban and rural end-of-life (EOF) cancer patients in China. Methods: Using respondent-driven sampling and face-to-face interviews, field research was conducted with a specialist questionnaire. Data were collected on 792 cancer patients who died between June 2013 and June 2016 in China. The determinants of household catastrophic expenditure were identified by multivariate logistic regression. Findings: It is found that more than 80% of cancer patients received life-extending treatment. Extremely high rates of CHE were identified among EOL cancer patients, at 94.3% for urban families and 96.1% for rural families. After spending for health, 84.1% of urban and 91.1% rural EOL cancer patient households were impoverished, falling below the poverty line. For both urban and rural households, income was the most significant factor associated with catastrophic health expenditure (CHE). Health insurance did not adequately compensate for CHE. Rural families experienced higher CHE, lower levels of health care utilization, a different mix of health care access and higher rates of borrowing for out-of-pocket (OOP) health care expenditures than urban families. Both urban and rural households suffered long-term economic disadvantage due to CHE and borrowing for OOP medical care expenses. Conclusions: EOL cancer patients experienced severe CHE, with families forced into poverty. With only about 1% of EOL cancer patients receiving palliative care, developing palliative care services and expanding the acceptance of palliative care in China is both urgent and essential. To help address impoverishment due to CHE, China should also develop targeted programs to reduce income inequality, especially rural-urban inequalities; increase access to health care; and accelerate health reform. Increasing the retirement age would provide households with more savings and wealth to withstand CHE. [ABSTRACT FROM AUTHOR]

Background: Inappropriate admissions cause excessive utilization of health services compared with outpatient services. However, it is still unclear whether inappropriate admissions cause excessive use of health services compared with appropriate admissions. This study aims to clarify the differences in the hospitalization performances between appropriately admitted inpatients and inappropriately admitted inpatients. Methods: A total of 2575 medical records were obtained after cluster sampling in three counties. Admission appropriateness was assessed by appropriateness evaluation protocol (AEP). The propensity score matching (PSM) was computed to match patients in treatment and control group with similar characteristics, and to examine the differences in the utilization of hospitalization services between the two groups. The samples were matched in two major steps in this study. In the first step, total samples were matched to examine the differences in the utilization of hospital services between the two groups using 15 individual covariates. In the second step, PSM was computed to analyze the differences between the two groups in different disease systems using 14 individual covariates. Results: For the whole sample, the inappropriate group has lower expenditure of hospitalization (EOH) (difference = − 0.12, p = 0.003) and shorter length of stay (LOS) (difference = − 0.73, p = 0.016) than the appropriate group. For number of clinical inspection (NCI), it has no statistically significant difference (difference = − 0.39, p = 0.082) between the two groups. Among different disease systems, no significant differences were observed between the two groups among EOH, LOS and NCI, except that the EOH was lower in the inappropriate group than that in the appropriate group for surgical disease (difference = − 0.169, p = 0.043). Conclusion: Inappropriate admissions have generated excessive health service utilization compared with appropriate admissions, especially for internal diseases. The departments in charge of medical services and hospital managers should pay high attention to the health service utilization of the inappropriately admitted inpatients. Relevant medical policies should be designed or optimized to increase the appropriateness in health care service delivery and precision in clinical pathway management. [ABSTRACT FROM AUTHOR]

Background: Tuberculosis patients often experience hospitalization. Inpatient services may result in high medical expenditures. It is important to explore the hospitalization rates of tuberculosis patients and the potential factors that are associated with admission rates and inpatient service expenditures.Methods: Data from patients diagnosed and treated at the No.3 hospital of Zhenjiang City from Apr. 2014 to Mar. 2015 were obtained. Univariate and multivariate statistical analyses were applied for the analysis of potential factors associated with admission rates, average length of stay and cost.Results: A total of 356 tuberculosis patients were treated at the No.3 hospital of Zhenjiang City. A total of 221 of the 356 patients were hospitalized. Sputum smear test results and type of health insurance were the potential factors associated with hospitalization rates. The average admission was (1.26 ± 0.64) per patient. The average length of stay of inpatients was 29.99 ± 25.83 days. Age, occupation, and sputum smear test were related to the average length of stay. The average total cost to inpatients was 13007.91 ± 5205.58 CNY. The sputum smear test results, type of health insurance, occupation and age were the main potential factors associated with TB inpatient expenditures.Conclusions: The admission rate of tuberculosis patients was high. Despite advances in TB insurance policies, there were substantial costs associated with TB diagnosis and treatment. TB patients still face a heavy financial burden. Health care providers should revise the service package and reform the health insurance regulations to ensure that TB patients receive appropriate care. [ABSTRACT FROM AUTHOR]

Background: Chronic disease has become one of the leading causes of poverty in China, which posed heavy economic burden on individuals, households and society, and accounts for an estimated 80% of deaths and 70% of disability-adjusted life-years lost now in China. This study aims to assess the effect of chronic diseases on health payment-induced poverty in Shaanxi Province, China.Methods: The data was from the 5th National Health Survey of Shaanxi Province, which was part of China's National Health Service Survey (NHSS) conducted in 2013. Totally, 20,700 households were selected for analysis. We used poverty headcount, poverty gap and mean positive poverty gap to assess the incidence, depth and intensity of poverty before and after health payment, respectively. Logistic regression models were further undertaken to evaluate the influence of percentage of chronic patients in households on the health payment-induced poverty with the control of other covariates.Results: In rural areas, the incidence of poverty increased 31.90% before and after health payment in the household group when the percentage of chronic patients in the households was 0, and the poverty gap rose from 932.77 CNY to 1253.85 CNY (50.56% increased). In the group when the percentage of chronic patients in the households was 1-40% and 41-50%, the poverty gap increased 76.78 and 89.29%, respectively. In the group when the percentage of chronic patients in the households was 51~ 100%, the increase of poverty headcount and poverty gap was 49.89 and 46.24%. In the logistic model, we found that the proportion of chronic patients in the households was closely related with the health payment-induced poverty. The percentage of chronic disease in the households increased by 1 %, the incidence of poverty increased by 1.01 times. On the other hand, the male household head and the household's head with higher educational lever were seen as protective factors for impoverishment.Conclusions: With the percentage of chronic patients in the households growing, the health payment-induced poverty increases sharply. Furthermore, the households members with more chronic diseases in rural areas were more likely to suffer poverty than those in urban areas. Our analysis emphasizes the need to protect households from the impoverishment of chronic diseases, and our findings will provide suggestions for further healthcare reforms in China and guidance for vulnerable groups. [ABSTRACT FROM AUTHOR]

Background: China has set up a universal coverage social health insurance system since the 2009 healthcare reform. Due to the inadequate funds, the social health insurance system reimbursed the inpatient expenditures with much higher ratio than outpatient expenditure. The gap in reimbursement ratios resulted in a rapid rising hospitalization rate but poor health outcomes among the Chinese population. A redistribution of social health insurance funds has become one of the main challenges for the performance of Social Health Insurance. Methods: Two comparable counties, Dangyang County and Zhijiang County, in Hubei Province of China, were sampled as the intervention group and the control group, respectively. The Social Health Insurance Management Department of the intervention group budgeted 600 yuan per capita per year to the patients with 3rd stage hypertension to cover their outpatient expenditures. The outpatient spending in the control group were paid out-of-pocket. The inpatient expenditures reimbursement policies in both groups were not changed. Besides, the Social Health Insurance Management Department of the intervention group budgeted 100 yuan per patient per year to township physicians and hospitals to provide health management services for the patients. While, the health management services in the control group were still provided by health workers. A Propensity Score Matching model and Difference-in-differences model were used to estimate the net effects of the intervention in dimensions of medical services utilization, medical expenditures, SHI reimbursement, and health outcomes. Results: One thousand, six hundred and seventy three pairs of patients were taken as valid subjects to conduct Difference-in-differences estimation after the Propensity Score Matching. The net intervention effect is to increase outpatient frequency by 3.3 (81.0%) times (P < 0.05), to decrease hospitalization frequency by 0.075 (− 60.0%) times (P < 0.05), and to increase the per capita total medical service utilization frequency by 3.225 (76.8%) times (P < 0.05). The per capita total medical expenditure decreased 394.2 (− 27.7%) yuan. The SHI reimbursed 90.3 yuan more per capita for the outpatient spending, but the per capita inpatient expenditure reimbursement and per capita total medical expenditure reimbursement decreased significantly by 282.6 (− 44.0%) yuan and 192.3 (− 28.5%) yuan, respectively (P < 0.05). The intervention reduced the per capita inpatient out-of-pocket expenditure and the per capita total out-of-pocket expenditure by 192.8 (− 36.7%) yuan and 201.9 (− 29.9%) yuan, respectively (P < 0.05). The intervention significantly decreased the diastolic blood pressure of the intervention group by 2.9 mmHg (P < 0.05) but had no significant impact on the systolic blood pressure (− 7.9 mmHg, P > 0.05). Conclusion: For China and countries attempting to establish a universal coverage SHI with inadequate funds, inpatient services were expensive but might not produce good health outcomes. Outpatient care for patients with chronic diseases should be fundamental, and outpatient expenditures should be reimbursed with a higher ratio. [ABSTRACT FROM AUTHOR]

Background: To explore the equity in health services in the rural areas, by studying the rural residents in two counties of Ningbo City, Zhejiang.Methods: Multi-stage stratified cluster random sampling method was performed to draw the study sample. Trained investigators conducted face to face interviews using a questionnaire. Rural residents were stratified into 5 income groups. Centralized index (CI) and risk ratios (RR) were used to assess the equity in health services and the impact of the New Cooperative Medical Scheme (NCMS).Results: The centralized index of the 2 weeks prevalence, two-week visiting rate and chronic disease prevalence among different income groups was - 0.0264, - 0.0076 and - 0.0160, respectively, while that of the hospitalization rate was 0.0006. The highest NCMS coverage rate, adjusted risk of disease and catastrophic health expenditure (CHE) rates were observed in lowest income groups (92.86, 4.94 and 32.21%, respectively. Two-week prevalence, chronic diseases prevalence and RR showed a declining trend with increasing income levels.Conclusion: NCMS has improved the service availability and reduced the economic burden of diseases. However, its impact on reducing the economic risk of illness and promoting equity in health services has not been significant. [ABSTRACT FROM AUTHOR]