Suchergebnisse

China's transition into a market economy has exerted some influence on the health sector in terms of a significant growth of facilities, but it has also produced a range of destabilizing social costs. This thesis analyzes the relations between healthcare pricing and payment reforms and the different delivery aspects such as the exemption program for the poor, public health programs for tuberculosis control and the provision of hospital services. A health economics and systems conceptual framework is used for analyzing aspects of the health systems in terms of market failures and the institutional response from governments and regulators. In study I, the exemption programs for hospitals where the poor are relieved of paying the price or user charges are analyzed. The study is a case study where patient records from nine hospitals were reviewed, together with interviews with key informants and community representatives. The study showed that the discount offered was limited, where only a minority of indigents received discounts and the hospitals lacked incentives for efficiently carrying out the programs. Study II investigates the effect of the new urban health insurance system on hospital charges. The study uses two tracers, acute appendicitis and normal childbirth, at six hospitals from two cities with different insurance systems. The result showed a lower rate of increase in hospitals charges in the city implementing the urban health insurance reform. Regression analysis showed contracting mechanisms and length of stay to be the main determinants for hospital charges. Study III analyzes the operation of TB control programs in a decentralized financial system. A case study was conducted in four counties with different economic developments in the Shandong province. Data was collected from a review of documents and interviews with patients and key informants. The study showed weak government support to the TB control program and less developed DOT (directly observed therapy) programs in the poorer counties. TB patients suffered heavy financial burdens. The decentralized financing system had negatively affected the provision of public health programs such as TB control programs. In study IV, the impact of retail price control of drugs on hospital drug expenditures was examined. The study is a case study at two hospitals. Total drug expenditures were analyzed based on financial records and a tracer, cerebral infarction, was used for an in-depth examination of prices, volume, expenditures and rationality of drug use. Findings showed that after the implementation of the drug pricing policy, total drug expenditures increased as rapidly as before. Drug expenditure per patient for cerebral infarction showed indistinct results, indicating that the regulation was not effective. Utilization rather than price was more determinative for drug expenditures. Study V investigates the development of revenues, costs and performance in the hospital sector. In a sample of 41 hospitals in two cities, the use of inputs, investments and productivity was estimated. The findings showed that hospitals had expanded their staff and invested in new medical equipment. The corresponding change of outputs in terms of outpatient and inpatient performance showed a slower increasing rate, resulting in a diminishing productivity rate over time. The market-oriented health care system in China is faced with different 'market failures' problems such as limited access to health services for the poor and the inaccuracy in relying on market mechanisms for services characterized by positive externalities, such as the public health programs. Financial autonomy has given health providers the incentives to maximize revenues. Government interventions to contain costs and improve efficiency show that a sole reliance on the price mechanism is insufficient and must be combined with other tools set by regulators and insurers.

BACKGROUND: Changes to the method of payment for healthcare providers, including pay‐for‐performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non‐randomised trials, controlled before‐after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta‐analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform ...

BACKGROUND: As a key part of the new round of health reform, the zero-markup drug policy (ZMDP) removed the profit margins of drug sales at public health care facilities, and had some effects to the operation of these institutions. This study aims to assess whether the ZMDP has different impacts between county general and traditional Chinese medicine (TCM) hospitals. METHODS: We obtained longitudinal data from all county general and TCM hospitals of Shandong province in 2007–2017. We used difference-in-difference (DID) method to identify the overall and dynamic effects of the ZMDP. RESULTS: On average, after the implementation of the ZMDP, the share of revenue from medicine sales reduced by 16.47 and 10.42%, the revenue from medicine sales reduced by 24.04 and 11.58%, in county general and TCM hospitals, respectively. The gross revenue reduced by 5.07% in county general hospitals. The number of annual outpatient visits reduced by 11.22% in county TCM hospitals. Government subsidies increased by 199.22 and 89.3% in county general and TCM hospitals, respectively. The ZMDP reform was not significantly associated with the revenue and expenditure surplus, the number of annual outpatient visits and the number of annual inpatient visits in county general hospitals, the gross revenue, the revenue and expenditure surplus and the number of annual inpatient visits in county TCM hospitals. In terms of dynamic effects, the share of revenue from medicine sales, revenue from medicine sales, and gross revenue decreased by 20.20, 32.58 and 6.08% respectively, and up to 28.53, 63.89 and 17.94% after adoption, while government subsidies increased by around 170 to 200% in county general hospitals. The number of annual outpatient visits decreased by 9.70% and up to 18.84% in county TCM hospitals. CONCLUSION: The ZMDP achieved its some initial goals of removing the profits from western medicines in county hospitals' revenue without disrupting the normal operation, and had different impacts between county general and TCM hospitals. ...

BACKGROUND: China has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas. This was partly achieved through the building of a three-tier health system in the 1950s, established as a linked network with health service facilities at county, township and village level, to extend services to the whole population. METHODS: We developed a Theory of Change to chart the policy context, contents and mechanisms that may have facilitated the establishment of the three-tier health service delivery system in rural China. We systematically synthesized the best available evidence on how China achieved universal access to essential services in resource-scarce rural settings, with a particular emphasis on the experiences learned before the 1980s, when the country suffered a particularly acute lack of resources. RESULTS: The search identified only three peered-reviewed articles that fit our criteria for scientific rigor. We therefore drew extensively on government policy documents, and triangulated them with other publications and key informant interviews. We found that China's three-tier health service delivery system was established in response to acute health challenges, including high fertility and mortality rates. Health system resources were extremely low in view of the needs and insufficient to extend access to even basic care. With strong political commitment to rural health and a "health-for-all" policy vision underlying implementation, a three-tier health service delivery model connecting villages, townships and counties was quickly established. We identified several factors that contributed to the success of the three-tier system in China: a realistic health human resource development strategy, use of mass campaigns as a vehicle to increase demand, an innovative financing mechanisms, public-private partnership models in the early stages of scale up, and an integrated approach to service delivery. An implementation process involving gradual adaptation and incorporation of the lessons learnt was also essential. CONCLUSIONS: China's 60 year experience in establishing a de-professionalized, community-based, health service delivery model that is economically feasible, institutionally and culturally appropriate mechanism can be useful to other low- and middle-income countries (LMICs) seeking to extend essential services. Lessons can be drawn from both reform content and from its implementation pathway, identifying the political, institutional and contextual factors shaping the three-tier delivery model over time.