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The aim of the thesis is - to assess equity in the provision, financing and utilization of health services in the study counties, after the launching of the Chinese health reform, in relation to income and health status, - to assess equity in utilization, financial barriers to care and poverty impact and the association of financial variables; alternative health insurance systerns and out-of-pocket financing and the association of non-financial variables; gender, age, education, occupation and geographical distance to health facilities. The data collection was carried out from 1993 to 1996. Retrospective, cross-sectional and panel data were collected in an expenditure review, a household survey (n=5756) and a provider survey (n=1064). The health expenditure review was designed as a natural experiment with 'twin' counties, one insurance-based and one out-of-pocket funded. The data sources were health accounts and interviews with officials in two of the counties. The household and provider surveys were based on multi-stage sampling. The provider survey involved health staff at county hospitals, township hospitals and village health stations and included curative, preventative and traditional medicine. Triangulation of methods and perspectives improved validity. The analysis was based on quantitative methods, including multivariate analysis. The study has shown that after the launching of the Chinese health reform (around 1985), the mix of health services shifted to less preventative and more curative services and a higher proportion of tertiary curative services. This was more pronounced in the insurance-based county. The majority of clinical doctors confirmed moral hazard by admitting that they alter prescriptions with consideration to the patients' financial status. A high level of inequity in illness, health care utilization, financing and financial difficulties was observed. Inequity in utilization was related to income, health insurance coverage and age. Registration at birth is a precondition for equal access. A gender bias was found in the high number of unregistered girls in five of the six counties, actual number of girls under 18 years at home exceeded the number reported in pregnancy histories by 22%. The elderly (8. 1% of the population) utilized a disproportionally small share (4%) of inpatient services. The ratio of negative pregnancy outcomes (miscarriage or still birth) increased by 170% from 1985-89 to 1990-95, while utilization of hospital delivery and qualified delivery supervision decreased. More than 90% of CMS (Cooperative Medical System) participants had qualified delivery supervision. The risk of adverse outcomes was 4.5 times higher for out-of-pocket paying mothers than for mothers with health insurance. CMS was associated with better health, three times less risk of illness with a duration of at least one month, five times less risk of financial difficulties and half the risk of care-induced debt. Other health insurance systerns were associated with higher costs, without reducing barriers to care or improving health. It is suggested that equity has ethical, political and fiscal aspects. The decreasing share of public financing of health services signals a need to involve the Ministry of Finance in discussions how to ensure adequate levels of public funding for rural health care. Professional norms and ethics need to be revived with the objective of creating a health system with quality-oriented incentives and improved equity.

Background: This paper examines two state-led public–private demand-side financial support programs aiming to raise hospital delivery rates in two neighbouring Indian states—Gujarat and Madhya Pradesh. The national Janani Suraksha Yojana (JSY) was complemented with a public–private partnership program Janani Sahayogi Yojana (JSaY) in Madhya Pradesh in which private obstetricians were paid to deliver poor women. A higher amount was paid for caesarean sections (CS) than for vaginal deliveries (VD). In Gujarat state, the state program Chiranjeevi Yojana (CY) paid private obstetricians a fixed amount for a block 100 deliveries irrespective of delivery mode. The two systems thus offered an opportunity to observe the influence of supplier-induced demand (SID) from opposite incentives related to delivery mode. Methods: The data from the two programs was sourced from the Departments of Health and Family Welfare, Governments of Gujarat and Madhya Pradesh, India. Results: In JSaY program the CS rate increased from 26.6 % (2007–2008) to 40.7 % (2010–2011), against the background rate for CS in Madhya Pradesh, of only 4.9 % (2004–2006). Meanwhile in CY program in Gujarat, the CS rate decreased to 4.3 % (2010–2011) against a background CS rate of 8.1 % (2004–2006). Conclusions: The findings from India are unique in that they not only point to a significant impact from the introduction of the financial incentives but also how disincentives have an inverse impact on the choice of delivery method. ; Correspondence Address: Bogg, L.; School of Health, Care and Social Welfare, Malardalen UniversitySweden

Abstract Background The rate of caesarean delivery (CD) in rural China has been rapidly increasing in recent decades. Due to the exorbitant costs associated with CD, paying for this expensive procedure is often a great challenge for the majority of rural families. Since 2003, the Chinese government has re-established the New Cooperative Medical Scheme (NCMS), aimed to improve the access of essential healthcare to rural residents and reduce financial burden owing to high out of pocket payments. This paper seeks to test the hypothesis that NCMS may provide service users and providers with financial incentives to select CD. It also assesses the effect of different health insurance reimbursement strategies of NCMS on CD rates in rural China. Methods Mixed quantitative and qualitative methods were adopted for data collection. Two cross-sectional household surveys were conducted with women having babies delivered in 2006 and 2009; 2326 and 1515 women, respectively, from the study sites were interviewed using structured questionnaires, to collect demographic and socio-economic data, maternal and child care characteristics and health-related expenditures. Focus group discussions (FGDs) and in-depth key informant interviews (KIIs) were undertaken with policy makers, health managers, providers and mothers to understand their perceptions of the influence of NCMS on the choices of delivery mode. Results The CD rates in the two study counties were 46.0 percent and 64.7 percent in 2006, increasing to 63.6 percent and 82.1 percent, respectively, in 2009. The study found that decisions on the selection of CD largely came from the pregnant women. Logistic regression analysis, after adjusting for socio-economic, maternal and fetal characteristics, did not indicate a significant effect of either proportional reimbursement or fixed amount reimbursement on the choice of CD for both study years. Interviews with stakeholders reflected that different reimbursable rates for CD and vaginal deliveries did not have a significant effect on controlling the rising CD rate in the study countries. Conclusion NCMS reimbursement strategies adopted in the study counties of China did not have a significant effect on the selection of CD for baby deliveries. The rapid rise of the CD rates of rural China has remained a serious issue. Other effective measures, such as health education to increase awareness of mothers' knowledge, and improving training of health staff in evidence-based delivery care, maybe could do more to promote rational baby delivery in rural China.

Introduction: Adherence to antiretroviral treatment (ART) is critical to maintaining health and good clinical outcomes in people living with HIV/AIDS. To address poor treatment adherence, low-cost interventions using mobile communication technology are being studied. While there are some studies that show an effect of mobile phone reminders on adherence to ART, none has reported on the costs of such reminders for national AIDS programmes. This paper aims to study the costs of mobile phone reminder strategies (mHealth interventions) to support adherence in the context of India's National AIDS Control Program (NACP). Methods: The study was undertaken at two tertiary level teaching hospitals that implement the NACP in Karnataka state, South India. Costs for a mobile phone reminder application to support adherence, implemented at these sites (i.e. weekly calls, messages or both) were studied. Costs were collected based on the concept of avoidable costs specific to the application. The costs that were assessed were one-time costs and recurrent costs that included fixed and variable costs. A sequential procedure for costing was used. Costs were calculated at national-programme level, individual ART-centre level and individual patient level from the NACP's perspective. The assessed costs were pooled to obtain an annual cost per patient. The type of application, number of ART centres and number of patients on ART were varied in a sensitivity analysis of costs. Results: The Indian NACP would incur a cost of between 79 and 110 INR (USD 1.27 - 1.77) per patient per year, based on the type of reminder, the number of patients on ART and the number of functioning ART centres. The total programme costs for a scaleup of the mHealth intervention to reach the one million patients expected to be on treatment by 2017 is estimated to be 0.36% of the total five-year national-programme budget. Conclusions: The cost of the mHealth intervention for ART-adherence support in the context of the Indian NACP is low and is facilitated by the low cost of mobile communication in the country. Extending the use of mobile communication applications beyond adherence support under the national programme could be done relatively inexpensively. ; EU/HIVIND

IntroductionAdherence to antiretroviral treatment (ART) is critical to maintaining health and good clinical outcomes in people living with HIV/AIDS. To address poor treatment adherence, low‐cost interventions using mobile communication technology are being studied. While there are some studies that show an effect of mobile phone reminders on adherence to ART, none has reported on the costs of such reminders for national AIDS programmes. This paper aims to study the costs of mobile phone reminder strategies (mHealth interventions) to support adherence in the context of India's National AIDS Control Program (NACP).MethodsThe study was undertaken at two tertiary level teaching hospitals that implement the NACP in Karnataka state, South India. Costs for a mobile phone reminder application to support adherence, implemented at these sites (i.e. weekly calls, messages or both) were studied. Costs were collected based on the concept of avoidable costs specific to the application. The costs that were assessed were one‐time costs and recurrent costs that included fixed and variable costs. A sequential procedure for costing was used. Costs were calculated at national‐programme level, individual ART‐centre level and individual patient level from the NACP's perspective. The assessed costs were pooled to obtain an annual cost per patient. The type of application, number of ART centres and number of patients on ART were varied in a sensitivity analysis of costs.ResultsThe Indian NACP would incur a cost of between 79 and 110 INR (USD 1.27–1.77) per patient per year, based on the type of reminder, the number of patients on ART and the number of functioning ART centres. The total programme costs for a scale‐up of the mHealth intervention to reach the one million patients expected to be on treatment by 2017 is estimated to be 0.36% of the total five‐year national‐programme budget.ConclusionsThe cost of the mHealth intervention for ART‐adherence support in the context of the Indian NACP is low and is facilitated by the low cost of mobile communication in the country. Extending the use of mobile communication applications beyond adherence support under the national programme could be done relatively inexpensively.