Wenhui Mao

Background Ethiopia has achieved impressive improvements in health outcomes and economic growth in the last decade but its total health spending is among the lowest in Africa. Ethiopia launched a Community-Based Health Insurance (CBHI) scheme in 2011 with a vision of reaching 80% of districts and 80% of its population by 2020. This study aimed to identify early achievements in scaling up CBHI and the challenges of such scale-up. Methods We interviewed 18 stakeholders working on health financing and health insurance in Ethiopia, using a semi-structured interview guide. All interviews were conducted in English and transcribed for analysis. We performed direct content analysis of the interview transcripts to identify key informants’ views on the achievements of, and challenges in, the scale-up of CBHI. Results Implementation of CBHI in Ethiopia took advantage of two key “policy windows”—global efforts towards universal health coverage and domestic resource mobilization to prepare count...

Background Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of heal...

In the coming years, about a dozen middle-income countries are excepted to transition out of development assistance for health (DAH) based on their economic growth. This anticipated loss of external funds at a time when there is a need for accelerated progress towards universal health coverage (UHC) is a source of concern. Evaluating country readiness for transition towards country ownership of health programmes is a crucial step in making progress towards UHC. We used in-depth interviews to explore: (1) the preparedness of the Nigerian health system to transition out of DAH, (2) transition policies and strategies that are in place in Nigeria, (3) the road map for the implementation of these policies and (4) challenges and recommendations for making progress on such policies. We applied Vogus and Graff’s expanded transition readiness framework within the Nigerian context to synthesize preparedness plans, gaps, challenges and stakeholders’ recommendations for sustaining the gains of ...

BackgroundThe COVID-19 pandemic has triggered several underlying vulnerabilities with potentially far reaching consequences in low- and middle-income countries (LMICs) like India. Evidence of physical and socio-economic vulnerabilities caused by the pandemic are emerging rapidly, but one area that has received limited attention so far, is the financial vulnerability COVID-19 causes for households and the government. This paper aims to assess the financial burden imposed on governments and households and the ability of households to afford the required medical costs. Methods and FindingsUsing publicly available data, we computed per-episode mean costs for COVID-19 diagnosis and curative care by government and households. The curative costs included per-episode expenditure for (i) home isolation, (ii) hospital isolation and (i) ICU support. Expenditure was estimated based on mean costs derived from government capped package rates set for private facilities. Households’ affordability w...

India is a lower-middle-income country (LMIC) with 21% of its population living below the international poverty line. Yet, its government health expenditure in 2016 was only 1.17% of its ross domestic product (GDP), a share that is even lower than the average for low-income countries. India also faces a shift in disease burden, with non-communicable diseases (NCDs) emerging as top causes of mortality while infectious diseases and maternal, neonatal, and nutritional health remain areas of concern. To address these challenges and improve healthcare access and affordability for poor and vulnerable populations, India launched Pradhan Mantri Jan Arogya Yojana (PM-JAY) in 2018 as a successor to the Rashtriya Swasthya Bima Yojana (RSBY) scheme. To further inform policy development, we synthesized the early experiences of PM-JAY by conducting a narrative review, focusing on the three dimensions of universal health coverage (UHC): population coverage, service coverage, and financial risk protection.

Objective To analyze the hospitalization expenses of cancer patients covered with byitem payment and quota payment packages,and probe into the impacts on such expenses for the two payment packages.Methods Inpatient records of 600 cancer patients were sampled by random from the medical insurance databases of Zhengzhou and Fuzhou to learn their hospitalization expenses and impact factors.Results Under the by-item payment package,the expenses of urban workers’ medical insurance were found higher than those of urban residents' medical insurance,with a per capita expense of RMB 32747.70 ± 32035.01 and 23035.83 ± 22875.65 respectively.Under the quota payment package however,there were no significant differences between expenses of the two kinds of inpatients,with a per capita expense of RMB 66043.41±47562.09 and 66576.54±73417.29 respectively.Conclusion There are gaps of reimbursement level between the two basic insurance schemes,which may not disappear in a short time.Under the by-it...

Many countries are now transitioning away from donor aid for health as they move from low- to middle-income status and see improved health outcomes. To promote better planning and preparedness for transition, many transition readiness assessment tools (TRAs) have been developed in recent years. The goal of this study was to identify and review existing TRAs to better understand the current landscape of how such tools are being used and the potential gaps among the currently available tools. There are several key limitations among existing tools. There are also many areas of overlap between tools, as well as clear gaps among the current tools available. For example, limited consideration has been given to emerging challenges for transitioning countries, such as demographic and disease transitions (e.g., aging populations and a shift in the burden of disease from infections to non-communicable diseases). Many critical health interventions, including vaccines and maternal and child hea...

Although the proportion of the world’s population living in poverty has declined substantially over the last two decades, the absolute number of people that live in poverty or vulnerable conditions has remained high. Nearly 70% of the poor now live in countries classified as middle-income.3 We conducted a document review and comparative analysis of six of the largest global health donors to better understand the extent to which they incorporate subnational poverty into their allocation decisions and programming. The donors we studied were Gavi, the Vaccine Alliance (Gavi); the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund); the President’s Emergency Plan for AIDS Relief (PEPFAR); the United States Agency for International Development (USAID)—specifically, its Global Health Bureau; the World Bank’s International Development Association (IDA); and the Government of Japan. We found that most donor high-level strategy documentation allude to the relationship betwe...

BackgroundUnder-five malaria in Nigeria is a leading cause of global child mortality, accounting for 95,000 annual child deaths. This is largely due to high out-of-pocket medical expenditure, which discourages care-seeking and use of effective antimalarials in the poorest households. Resultingly, Nigeria has some of the worst indicators of child health equity in the world, stressing the need to evaluate the outcomes of potential interventions across socioeconomic lines. Methods Using a decision tree model, we conducted an extended cost-effectiveness analysis of subsidies covering the direct and indirect costs of case management of under-five malaria in Nigeria. We estimated the number of child deaths averted, out-of-pocket (OOP) expenditure averted, cases of catastrophic health expenditure (CHE) averted, and cost of implementation. We assumed pro-poor increase in treatment uptake, as the malaria burden in Nigeria disproportionately affects the poor.FindingsFully subsidizing direct m...

Background The detection of drug-resistant tuberculosis (DR-TB) is a major health concern in China. We aim to summarize interventions related to the screening and detection of DR-TB in Jiangsu Province, analyse their impact, and highlight policy implications for improving the prevention and control of DR-TB. Methods We selected six prefectures from south, central and north Jiangsu Province. We reviewed policy documents between 2008 and 2019, and extracted routine TB patient registration data from the TB Information Management System (TBIMS) between 2013 and 2019. We used the High-quality Health System Framework to structure the analysis. We performed statistical analysis and logistic regression to assess the impact of different policy interventions on DR-TB detection. Results Three prefectures in Jiangsu introduced DR-TB related interventions between 2008 and 2010 in partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and the Bill & Melinda Gat...

China has the highest number of hepatitis B and C cases globally. Despite remarkable achievements, China faces daunting challenges in achieving international targets for hepatitis elimination. As part of a large-scale project assessing China’s progress in achieving health-related Sustainable Development Goals using quantitative, qualitative data and mathematical modelling, this paper summarises the achievements, gaps and challenges, and proposes options for actions for hepatitis B and C control. China has made substantial progress in controlling chronic viral hepatitis. The four most successful strategies have been: (1) hepatitis B virus childhood immunisation; (2) prevention of mother-to-child transmission; (3) full coverage of nucleic acid amplification testing in blood stations and (4) effective financing strategies to support treatment. However, the total number of deaths due to hepatitis B and C is estimated to increase from 434 724 in 2017 to 527 829 in 2030 if there is no imp...

China has made profound progress in advancing universal health coverage (UHC) over the past two decades. New Cooperative Medical Scheme (NCMS) was initiated in 2003 to provide health insurance coverage to rural population. Its benefit packages and cost-sharing mechanism have changed significantly over time. This study aims to assess the impact of changing NCMS policies on NCMS enrollees’ service utilisation, medical financial burden and equity between 2003 and 2013. Data are from China National Health Services Survey (NHSS) which is conducted every 5 years. We used the subsample of NHSS that were enrolled in NCMS in 2003, 2008 and 2013. From 2003 to 2013, we found increased service utilisation and an elimination of inequity in service utilisation with respect to income. Contradicting prior findings of increasing financial burden after the NCMS implementation, we identified significant protective effect of NCMS against financial risks, and a reduction in percentage of households with...

Abstract Background Chinese global health aid has expanded tremendously since the 2000s. Unlike many donors, China has no official aid reporting obligations, nor does it voluntarily disclose detailed aid information. Therefore, several third parties have attempted to estimate China's health aid footprint. However, current estimates use varied definitions of health aid, geographic regions, and time spans. These distinct methodological approaches make comparisons of Chinese aid to other aid donors difficult. Our study builds on previous tracking efforts and improves on them by creating a standardised estimate using commonly accepted definitions of aid and frameworks for categorising health projects. Methods We categorised AidData's Chinese Official Finance Dataset health-related projects according to health aid frameworks from the Organization for Economic Co-operation and Development (OECD) and the Institute for Health Metrics and Evaluation (IHME). Only projects that fitted the definition of official development assistance were included. We analysed data by both total project count and financial value to assess priority health-aid focus areas for China. We also provide an updated estimate for projects with missing financial values in AidData's database by applying the median cost of similar projects to projects with missing financial values, allowing for comparison with other donors. Findings Between 2000 and 2014, China funded 620 health-related aid projects, which made up more than 20% of its total aid project portfolio. Most of these projects were located in Africa. According to the OECD framework, the priority focus areas of these 620 projects were: basic health care, such as medical teams, drugs, and medicine (n=244, 36%); malaria control (118, 19%); medical services, such as specialty equipment, infrastructure and services (108, 17%); and basic health infrastructure (78, 13%). According to the IHME framework, health-systems strengthening accounted for 70% (n=434) of total projects, primarily due to China's contributions to human resources for health, infrastructure, and equipment. The only other significant allocation under the IHME framework was malaria (n=118, 19%). When we estimate missing financial values, we noted that China was the fourth largest health aid donor to African countries from 2008–2014, after the USA, UK, and Canada. Interpretation These findings enable a better understanding of Chinese health aid in the absence of transparent aid reporting. Such understanding could lead to better coordination, collaboration, and resource allocation for both fellow donors and recipient countries. Funding Huang Fellows Program, Duke University Science & Society (PK).

Abstract Background Despite relative affluence, Jiangsu, China, faces challenges brought by disease burdens, regional disparities, ageing, and migrant workforce, in achieving the health-related Sustainable Development Goals (SDGs) and Healthy Jiangsu 2030 goals. Therefore, we aimed to assess the current situation, gaps, and projection of Jiangsu attaining these goals. Methods We did a systematic analysis using a combination of quantitative and qualitative methods. We collected quantitative data from national and provincial health-related government agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016). We did semi-structured interviews with key stakeholders at provincial and sub-provincial levels. We also included other policy documents and grey literatures. On the basis of the model developed by the SDG Collaborators of GBD 2016, we did projections to assess the attainment of the quantitative health targets in Jiangsu. We also explored the gender disparities. Our study protocol was reviewed and approved by the Institutional Review Board of Duke University. Findings At baseline in 2015, Jiangsu performed well in indicators related to child under-nutrition and maternal and child health, meeting targets of the SDGs early. By 2030, Jiangsu is expected to meet targets in mental health, environmental health, and universal health coverage. However, our projections indicate that Jiangsu will not achieve the targets in exclusive breastfeeding, child overweight, infectious diseases, and non-communicable diseases, according to current trajectories. 7–28 day exclusive breastfeeding rate is expected to increase to 25·6%, a huge gap compared with the 6-month 50% target. Child overweight rate (1–4 years) was projected to increase by 2·6% compared with the zero increase target. The incidence of HIV/AIDS were projected to decrease to 0·9 per 100 000 population and tuberculosis to 15·3 per 100 000 population in 2030, suggesting that ending these epidemics would be highly improbable. New cases of hepatitis B virus and hepatitis C virus infections were projected to decrease by 45·3%, which is far from the 90% target. Large gender disparity was seen in non-communicable diseases, such as premature mortality and smoking rates. Interpretation The provincial Government of Jiangsu needs to take immediate and concerted actions to meet the SDGs and the Healthy Jiangsu 2030 goals. Funding Bill & Melinda Gates Foundation (grant number OOP1148464 )

Background: In China, cancer deaths account for one-fifth of all deaths and exerts a heavy toll on patients, families, the healthcare system, and society as a whole. This study aims to examine socio-economic and rural-urban differences in treatment, health service utilization and catastrophic health expenditure (CHE) among cancer patients in China, and to investigate the association of different treatment types with health service utilization and CHE. Methods: We analyzed two waves of nationally representative data from the China Health and Retirement Longitudinal Study with 17,224 participants in 2011 and 19,569 participants in 2015. The main treatment types evaluated for cancer included Chinese traditional medicine (TCM), western modern medication excluding TCM, both western modern medications and TCM, surgery, and radiation/chemotherapy. CHE is defined as the point at which annual household health payments exceeded 40% of non-food household consumption expenditure. Multivariable regression models were performed to examine the association of cancer treatments with health service utilization and as well as incidence of CHE. Findings: The age-adjusted prevalence of cancer is 1.37% for 2011 and 1.84% for 2015. Approximately half of the cancer patients utilized treatment for their disease, with a higher proportion of urban residents (54%) than rural residents (46%) receiving cancer treatment in 2015. CHE declined by 22% in urban areas (25% in 2011 and 19% in 2015) but increased by 31% in rural areas (25% in 2011 to 33% in 2015). There was a positive association of cancer treatment with outpatient visit (Adjusted Odds Ratio (AOR)=2.098, 95% CI =1.453, 3.029), admission to hospital (AOR=1.961, 95% CI=1.346, 2.857), as well as CHE (AOR=1.796, 95% CI=1.231, 2.620). Chemotherapy (AOR: 2.53, 95% CI: 1.55, 4.12) and surgery (surgery: AOR: 2.15, 95% CI: 1.44, 3.20) were each associated with a 2-fold increased risk of CHE. Interpretation: The burden of cancer among Chinese adults is increasing and about one- fourth cancer patients experienced CHE. Yet disparities among urban-rural, and different socio-economic status still exist. The disparity in CHE has actually increased between the rural and urban population. To reduce financial burden of cancer and bridge the socio-economic gaps, meaningful changes to improve health insurance benefit packages are needed to ensure universal, affordable and patient-centered health coverage for the Chinese cancer patients. Funding Statement: None. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The Biomedical Ethics Review Committee of Peking University approved the CHARLS study, and all interviewees were required to provide informed consent. The ethical approval number was IRB00001052–11015.

BackgroundGhana’s shift from low-income to middle-income status will make it ineligible to receive concessional aid in the future. While transition may be a reflection of positive changes in a country, such as economic development or health progress, a loss of support from donor agencies could have negative impacts on health system performance and population health. We aimed to identify key challenges and opportunities that Ghana will face in dealing with aid transition, specifically from the point of view of country-level stakeholders.MethodsWe conducted key informant interviews with 18 stakeholders from the government, civil society organisations and donor agencies in Ghana using a semistructured interview guide. We performed directed content analysis of the interview transcripts to identify key themes related to anticipated challenges and opportunities that might result from donor transitions.ResultsOverall, stakeholders identified challenges more frequently than opportunities. A...

Abstract Background New Rural Cooperative Medical Scheme (NCMS) in China rapidly achieved over 90% population coverage since its launch in 2003, and then gradually improved its service coverage and financial protection. Most published studies were conducted in the early years of NCMS or only focused on sub-regions in China. We aimed to provide the first national, comprehensive and up-to-date assessment of the equity of effects of NCMS on service use, medical financial burden, and health from 2003 to 2013. Methods Using three waves of the National Health Service Surveys in 2003, 2008, and 2013 (total sample size >600 000 individuals), we classified NCMS enrollees into five income quintiles and analysed national trends in health service use, and catastrophic expenditure over the study period. To further examine the effects of NCMS on trends of catastrophic medical expenditure across income quintiles, three multi-variate logistic regression models were used. Findings From 2003 to 2013, inequity in health service use was greatly reduced with respect to income. In 2013, prevalence of outpatient service use was 14·5% in the lowest income quintile and 13·2% in the highest income quintile; prevalence of inpatient service use was 8·6% in the lowest and 7·8% in the highest income quintile. In 2003, prevalence of outpatient service use was 13·5% in the lowest income quintile and 15·2% in highest income quintile; prevalence of inpatient service use was 1·8% in the lowest and 4·1% in the highest income quintile. Contradicting previous findings of increased financial burden after NCMS implementation, we identified improvements in financial risk protection (odds ratio 0.66, 95% CI 0·57–0·77, for catastrophic medical expenditure in 2013 relative to 2003). The proportion of households with catastrophic medical expenditure only increased in the lowest income quintile (from 16·1% in 2003 to 24·7% in 2013) but decreased in all other income quintiles. Interpretation Improvements in health equity and financial risk protection were seen after 10 years of the NCMS. However, medical financial burdens increased among the poorest people, highlighting the importance of targeting the lowest-income rural residents in future reforms of rural health insurance and medical financial assistance. Funding This study did not receive funding from any agency.

Background China’s rapidly aging population has led to many challenges related to the health care delivery and financing. Since 2007, the Urban Residents Basic Medical Insurance (URBMI) program has provided financial protection for older adults living in urban areas not already covered by other health insurance schemes. We conducted a national level assessment on this population’s health needs and health service utilization. Methods Records for 9646 individuals over the age of 60 were extracted for analysis from two National Health Service Surveys conducted in 2008 and 2013. Multiple regression models were used to examine associations between socioeconomic factors, health needs and health service utilization while controlling for demographic characteristics and survey year. Results Self-reported illness, especially non-communicable diseases (NCDs) increased significantly between 2008 and 2013 regardless of insurance enrollment, age group or income level. In 2013, over 75% of individ...

Abstract Background China has a population that is rapidly ageing. This rapid growth raises many challenges such as financing and delivery of health care. The Urban Residents Basic Medical Insurance (URBMI) has provided financial protection for the urban elderly not covered by other health insurance schemes since 2007. We therefore aimed to do a national level assessment on the changes in perceived health needs and use of health services of the elderly enrolled in URBMI. Methods We extracted data from two waves (2008 and 2013) of the National Health Service Surveys. We included eligible individuals aged 60 years or over and enrolled in URBMI for analysis. Our primary measures were self-reported diagnosis of non-communicable diseases (NCDs), outpatient visits in the past 2 weeks, hospital admissions within the past year, and proportion of forgone necessary admissions referred, which were analysed by age groups (60–69 years, 70–79 years, and ≥80 years) and income levels (low, middle, and high). We used multivariate regression models to estimate associations of socioeconomic factors (age and income groups) and perceived health demand to the use of health services with control of demographic characters (sex, household size, marriage status, and education) and year of survey (2008 as base). The National Health Services Surveys were reviewed and approved by National Statistics Bureau and all participants gave oral consent to participate in the study. Findings From June 1, 2008, to Sep 30, 2013, 7634 individuals were eligible for analysis, in whom self-reported prevalence rates of NCDs increased from 67·9% (553 of 815) to 77·8% (5305 of 6819). 89·1% (1792 of 2012) of individuals aged 70–79 years reported with NCDs in 2013, which is 9·0% higher than those aged 80 years or over and 17·6% higher in those aged 60–69 years. 80·1% (1821 of 2273) of the elderly from the middle-income group reported having NCDs, whereas 78·9% (1793 of 2273) from the high-income group and 75·4% (1714 of 2273) from the low-income group reported having NCDs in 2013. Between 2008 and 2013, outpatient visits increased from 23·7% (193 of 815) to 27·0% (1841 of 6819) and hospital admissions increased from 13·3% (108 of 815) to 16·6% (1132 of 6819). Outpatient visits increased from 24·8% to 32·1% for those aged 70–79 years and 19·7% to 26·7% for those aged 80 years or over, but remained at 24·5% for individuals aged 60–69 years. The high-income group had the highest increase from 23·0% to 31·1% whereas the low-income group had a decrease from 26·3% to 22·2%. Hospital admissions increased among all groups, with the 70–79 years' age group and the middle-income group having the largest increase. Proportion of forgone necessary admission reduced from 29·4% to 17·7%, and both low-income and middle-income groups had more than 20% reduction between 2008 and 2013. Age, income, and survey year significantly influenced outpatient visits whereas education, age, income, self-reported NCDs, and survey year were significant influential factors for hospital admission. Interpretation The use of overall services increased and forgone necessary admission decreased after the implementation of URBMI, indicating the improvement of access to health services. However, outpatient use favoured those in the high-income group and calls for further attention on equity. Additionally, the prevalence rate of NCDs among the elderly in urban regions increased sustainably and action plans on health promotion and primary prevention of NCDs should be implemented. The benefit package of insurance should also support the care of NCDs. Funding None.

Background Tuberculosis is a leading cause of death worldwide and has become a high global health priority. Accurate country level surveillance is critical to ending the pandemic. Effective routine reporting systems which track the course of the epidemic are vital in addressing TB. China, which has the third largest TB epidemic in the world and has developed a reporting system to help with the control and prevention of TB, this study examined its effectiveness in Eastern China. Methods The number of TB cases reported internally in two hospitals in Eastern China were compared to the number TB cases reported by these same hospitals in the national reporting systems in order to assess the accuracy of reporting. Qualitative data from interviews with key health officials and researcher experience using the TB reporting systems were used to identify factors affecting the accuracy of TB cases being reported in the national systems. Results This study found that over a quarter of TB cases r...

In 2009, China launched a major health-care reform and pledged to provide all citizens with equal access to basic health care with reasonable quality and financial risk protection. The government has since quadrupled its funding for health. The reform's first phase (2009-11) emphasised expanding social health insurance coverage for all and strengthening infrastructure. The second phase (2012 onwards) prioritised reforming its health-care delivery system through: (1) systemic reform of public hospitals by removing mark-up for drug sales, adjusting fee schedules, and reforming provider payment and governance structures; and (2) overhaul of its hospital-centric and treatment-based delivery system. In the past 10 years, China has made substantial progress in improving equal access to care and enhancing financial protection, especially for people of a lower socioeconomic status. However, gaps remain in quality of care, control of non-communicable diseases (NCDs), efficiency in delivery, control of health expenditures, and public satisfaction. To meet the needs of China's ageing population that is facing an increased NCD burden, we recommend leveraging strategic purchasing, information technology, and local pilots to build a primary health-care (PHC)-based integrated delivery system by aligning the incentives and governance of hospitals and PHC systems, improving the quality of PHC providers, and educating the public on the value of prevention and health maintenance.

Background China’s rapidly aging population is raising many challenges for the delivery and financing of health care. The Urban Residents Basic Medical Insurance (URBMI) has provided financial protection for the urban elderly population not covered by other health insurance schemes since 2007. We conducted a national level assessment to measure on the perceived health needs of this population as well as their use of health services. Methods Data on individuals over the age of 60 were extracted from two National Health Service Surveys conducted in 2008 and 2013. Multivariate regression models were used to estimate associations of socioeconomic factors and perceived health needs with the use of health services while controlling for demographic characteristics and year of survey. Findings Perceived health needs increased significantly between 2008 and 2013, regardless of insurance enrollment, age group or income level. In 2013, over 75% of individuals reported having at least one Non-c...

This study aimed to examine the availability, use, and affordability of medicines in urban China following the 2009 Health Care System Reform that included implementation of universal health coverage (UHC). This longitudinal study was performed in Hangzhou (high income, eastern China) and Baoji (lower income, western China). Five yearly household surveys were conducted (one each year from 2009 to 2013) to evaluate the impact of UHC on medicines use and expenditure, and a health facility survey was conducted in 2013 to evaluate availability of medicines. A cohort of over 800 households in Hangzhou and Baoji was established in 2009, and 20 hospitals were included in the health facility survey. Medicines use was determined using data from health facility and household surveys. An average, two-week out-of-pocket medicines expenditure was calculated to assess the affordability of medicines. The number of medicines stocked in primary health facilities in Hangzhou decreased, while the numb...

Cancer accounts for one-fifth of the total deaths in China and brings heavy financial burden to patients and their families. Chinese government has made strong commitment to develop three types of social medical insurance since 1997 and recently, more attempts were invested to provide better financial protection. To analyze health services utilization and financial burden of insured cancer patients, and identify the gaps of financial protection provided by insurance in urban China. A random sampling, from Urban Employee's Basic Medical Insurance claim database, was performed in 4 cities in 2008 to obtain insurance claim records of cancer patients. Services utilization, medical expenses and out-of-pocket (OOP) payment were the metrics collected from the insurance claim database, and household non-subsistence expenditure were estimated from Health Statistics. Catastrophic health expenditure was defined as household's total out-of-pocket payments exceed 40% of non-subsistence e...

The State Council encouraged the involvement of commercial insurance companies (CICs) in the development of the Insurance Program for Catastrophic Diseases (IPCD), yet its implementation has rarely been reported. We collected literature and policy documentation and conducted interviews in 10 cities with innovative IPCD policies to understand the details of the implementation of IPCD. IPCDs are operated at the prefectural level in 14 provinces, while in 4 municipalities and 6 provinces, unified IPCDs have been implemented at higher levels. The contribution level varied from 5% to 10% of total Basic Medical Insurance (BMI) funds or CNY10-35 per beneficiary in 2015. IPCD provides an additional 50% to 70% reimbursement rate for the expenses not covered by BMI with various settings in different locations. Two models of CIC operation of IPCD have been identified according to the financial risks shared by CICs. Either the local department of Human Resources and Social Security or a third p...

Before the new round of healthcare reform in China, primary healthcare providers could obtain a fixed 15 % or greater mark-up of profits by prescribing and selling medicines. There were concerns that this perverse incentive was a key cause of irrational medicine use. China's new Essential Medicines Program (EMP) was launched in 2009 as part of the national health sector reform initiatives. One of its core policies was to eliminate primary care providers' economic incentives to overprescribe or prescribe unnecessarily expensive drugs, which were regarded as consequences of China's traditional financing system for health institutions. The objective of the study was to measure changes in prescribing patterns in primary healthcare facilities after the removal of the economic incentives for physicians to overprescribe as a result of the implementation of the EMP. A comparison design was applied to 8,258 prescriptions in 2007 and 8,278 prescriptions in 2010, from 83 primary healthcare facilities nationwide. Indicators were adopted to evaluate medicine utilization, which included overall number of medicines, average number of Western and traditional Chinese medicines, pharmaceutical expenditure per outpatient prescription, and proportion of prescriptions that contained two or more antibiotics. We further assessed the use of medicines (antibiotics, infusion, hormones, and intravenous injection) per disease-specific prescription for hypertension, diabetes, coronary artery heart disease, bronchitis, upper respiratory tract infection, and gastritis. A difference-in-difference analysis was employed to evaluate the net policy effect. Overall changes in indicators were not found to be statistically significant between the 2 years. The results varied for different diseases. The number of Western drugs per outpatient prescription decreased while that of traditional Chinese medicines increased. Overuse of antibiotics remained an extensive problem in the treatment of many diseases, though there was some significant improvement in certain diseases, like diabetes in rural areas. Medicine expenditure per prescription also decreased. It seems that the removal of a perverse economic incentive alone would not lead to improvement of healthcare providers' prescribing patterns. The rationality of the Essential Medicines List and the lack of…