Development of the China's list of ambulatory care sensitive conditions (ACSCs): a study protocol.

BACKGROUND: The hospitalization rate of ambulatory care sensitive conditions (ACSCs) has been recognized as an essential indicator reflective of the overall performance of healthcare system. At present, ACSCs has been widely used in practice and research to evaluate health service quality and efficiency worldwide. The definition of ACSCs varies across countries due to different challenges posed on healthcare systems. However, China does not have its own list of ACSCs. The study aims to develop a list to meet health system monitoring, reporting and evaluation needs in China. METHODS: To develop the list, we will combine the best methodological evidence available with real-world evidence, adopt a systematic and rigorous process and absorb multidisciplinary expertise. Specific steps include: (1) establishment of working groups; (2) generations of the initial list (review of already published lists, semi-structured interviews, calculations of hospitalization rate); (3) optimization of the list (evidence evaluation, Delphi consensus survey); and (4) approval of a final version of China's ACSCs list. Within each step of the process, we will calculate frequencies and proportions, use descriptive analysis to summarize and draw conclusions, discuss the results, draft a report, and refine the list. DISCUSSION: Once completed, China's list of ACSCs can be used to comprehensively evaluate the current situation and performance of health services, identify flaws and deficiencies embedded in the healthcare system to provide evidence-based implications to inform decision-makings towards the optimization of China's healthcare system. The experiences might be broadly applicable and serve the purpose of being a prime example for nations with similar conditions.

Universal health coverage in China part 2: addressing challenges and recommendations.

This report analyses the underlying causes of China's achievements and gaps in universal health coverage over the past 2 decades and proposes policy recommendations for advancing universal health coverage by 2030. Although strong political commitment and targeted financial investment have produced positive outcomes in reproductive, maternal, newborn, and child health and infectious diseases, a fragmented and hospital-centric delivery system, rising health-care costs, shallow benefit coverage of health insurance schemes, and little integration of health in all policies have restricted China's ability to effectively prevent and control chronic disease and provide adequate financial risk protection, especially for lower-income households. Here, we used a health system conceptual framework and we propose a set of feasible policy recommendations that draw from international experiences and first-hand knowledge of China's unique institutional landscape. Our six recommendations are: instituting a primary care-focused integrated delivery system that restructures provider incentives and accountability mechanisms to prioritise prevention; leveraging digital tools to support health behaviour change; modernising information campaigns; improving financial protection through insurance reforms; promoting a health in all policy; and developing a domestic monitoring framework with refined tracer indicators that reflects China's disease burden.

Universal health coverage in China part 1: progress and gaps.

Over the past 2 decades, China has made remarkable progress in health-care service coverage, especially in the areas of reproductive, maternal, newborn, and child health, infectious diseases, and service capacity and access. In these areas, coverage is comparable to those in high-income countries. Inequalities of service coverage in these areas have been reduced. However, there remain large gaps in the service coverage of chronic diseases. There has been little progress in controlling risk factors of chronic diseases in the past 10 years. Service coverage for most chronic conditions is lower than in high-income countries. Moreover, China has disproportionately high incidences of catastrophic health expenditure compared with countries with similar economic development. This paper comprehensively evaluates China's progress towards universal health coverage by identifying the achievements and gaps in service coverage and financial risk protection that are crucial to achieve universal health coverage goals by 2030.

Factors influencing engagement in online dual practice by public hospital doctors in three large cities: A mixed-methods study in China.

Background: In the digital age, a rising number of public sector doctors are providing private telemedicine and telehealth services on online health care platforms. This novel practice pattern - termed online dual practice - may profoundly impact health system performance in both developed and developing countries. This study aims to understand the factors influencing doctors' engagement in online dual practice. Methods: Using a mixed-methods design, this study concurrently collects quantitative demographic and practice data (n = 71 944) and semi-structured interview data (n = 32) on secondary and tertiary public hospital doctors in three large Chinese cities: Beijing, Shanghai and Guangzhou. We use the quantitative data to examine the prevalence of the online dual practice and its associated factors via the binary logit regression model. The qualitative data are used to further explore associated factors of online dual practice via thematic analysis. The findings about associated factors from the two parts were merged using the categories of personal, professional, and organisational characteristics. Results: Our quantitative analysis shows that at least 47.1% of public hospital doctors are involved in online dual practice. The shares in Beijing, Shanghai, and Guangzhou are 43.7%, 53.1%, and 44.8%, respectively. This practice is more prevalent among doctors who are male, senior, and non-managerial. Different specialties, hospital ownership, hospital levels, and locations are also significantly associated with this practice. The qualitative analysis further suggests that financial returns, perceived effectiveness of telemedicine, and hospital directors' attitude towards telemedicine may affect doctors' engagement with online dual practice. Conclusions: Online dual practice is prevalent among doctors at tertiary and secondary public hospitals in Beijing, Shanghai, and Guangzhou. Personal, professional, and organisational characteristics are all associated with doctors' choice to engage in online dual practice. The findings in this study provide implications for promoting telemedicine adoption and developing relevant regulatory policies in China and other countries.

Understanding financial risk protection in China's health system: a descriptive analysis using data from multiple national household surveys.

BACKGROUND: Providing financial risk protection is one of the fundamental goals of health systems. Catastrophic health expenditure (CHE) and medical impoverishment (MI) are two common indicators in evaluating financial risk protection in health. As China continues its health system reform to provide accessible and affordable health care, it is important to have a clear understanding of China's progress in financial risk protection. However, past research showed discrepancies in the incidence of CHE and MI. In this article, using data from four national household surveys, we analyzed levels and characteristics of CHE and MI in China under different definitions. METHODS: We used multiple conventional thresholds for CHE and MI to comprehensively describe the levels of financial risk protection in China. We used data from four national household surveys to measure the incidence of CHE and MI, and their inequalities by urban/rural status and by income quartiles. The Probit regression model was used to explore influencing factors of CHE and MI. RESULTS: We found that the incidences of CHE and MI were largely consistent across four national household surveys, despite different sampling methods and questionnaire designs. At the 40% nonfood expenditure threshold, the incidence of CHE in China was 14.95%-17.73% across four surveys during the period of 2016-2017. Meanwhile, at the 1.9 US dollars poverty line, the incidence of MI was 2.01%-5.63%. Moreover, rural residents, lower-income subgroups, and smaller households were faced with higher financial risks from healthcare expenditures. Although positive progress in financial risk protection has been achieved in recent years, China has disproportionately high incidences of CHE and MI, compared to other countries. CONCLUSION: China has large margins for improvements in risk financial protection, with large inequalities across subgroups. Providing better financial protection for low-income groups in rural areas is the key to improve financial protection in China.

Understanding Impacts of Online Dual Practice on Health System Performance: A Qualitative Study in China.

The outbreak of the COVID-19 pandemic has boosted the global development of online healthcare platforms. An increasing number of public hospital doctors are providing online services on private third-party healthcare platforms, creating a new form of dual practice-online dual practice. To explore the impacts of online dual practice on health system performance as well as potential policy responses, we undertook a qualitative approach that uses in-depth interviews and thematic analysis. Following a purposive sampling, we interviewed 57 Chinese respondents involved in online dual practice. We asked respondents for their opinions on the effects of online dual practice on access, efficiency, quality of care, and advice on regulatory policy. The results suggest that online dual practice can generate mixed impacts on health system performance. The benefits include improved accessibility due to increased labor supply of public hospital doctors, better remote access to high-quality services, and lower privacy concerns. It can improve efficiency and quality by optimizing patient flows, reducing repetitive tasks, and improving the continuity of care. However, the potential distraction from designated work at public hospitals, inappropriate use of virtual care, and opportunistic physician behaviors may undermine overall accessibility, efficiency, and quality. Countries should mitigate these adverse consequences via regulations that are appropriate to their healthcare system context, policy priority, and governance capacity.

Changes of equality of medical service utilization in China between 1993 and 2018: findings from six waves of nationwide household interview survey.

BACKGROUND: Changes in China's health care system in the last three decades was remarkable. The current study aims on examine the change of equality of health care utilization in mainland China based on a nationwide household interview survey. METHODS: We used household interview data extracted from six waves of National Health Service Survey between 1993 and 2018. Changes of health care utilization were descripted. Equality of the utilization were examined with univariate meta-regression across urban and rural areas, socioeconomic development regions and income groups. RESULTS: The proportion of outpatient visits within last two weeks experienced a decrease from 17.0% in 1993 to 13.0% in 2013 and bounced back to 24.0% in 2018. The age-standardized trend remained unchanged. Hospitalization in the last 12 month increased from 2.6% in 1998 to 13.8% in 2018. The perceived unmet need of hospital admission fell from 35.9% in 1998 to 21.5% in 2018. The gaps in health care utilization between urban and rural areas, across regions and by income groups have been narrowed, implying improved equality of using medical services in the last two and a half decades. CONCLUSION: China has experienced significant increases in health care utilization over the past 25 years. Meanwhile, the unmet needs for health care decreased remarkably and the equality of health care utilization improved significantly. These results imply significant achievements in health service accessibility in China.

Provincial variations in catastrophic health expenditure and medical impoverishment in China: a nationwide population-based study.

Background: Financial protection, as a key dimension of Universal Health Coverage (UHC), has been under increasing attention in recent years. A series of studies have examined the nationwide extent of catastrophic health expenditure (CHE) and medical impoverishment (MI) in China. However, disparities in financial protection at the province level have rarely been studied. The aim of this study was to investigate provincial variations in financial protection as well as its inequality across provinces. Methods: Using data from the 2017 China Household Finance Survey (CHFS), this study estimated the incidence and intensity of CHE and MI for 28 Chinese provinces. Ordinary least square (OLS) estimation, using robust standard errors, was used to explore the factors associated with financial protection at the province level. Moreover, this study examined the urban-rural differences in financial protection within each province, and calculated the concentration index of CHE and MI indicators for each province using household income per capita. Findings: The study revealed large provincial variations in financial protection within the nation. The nationwide CHE incidence was 11.0% (95% CI: 10.7%, 11.3%), ranging from 6.3% (95% CI: 5.0%, 7.6%) in Beijing to 16.0% (95% CI: 14.0%, 18.0%) in Heilongjiang; the national MI incidence was 2.0% (95% CI: 1.8%, 2.1%), ranging from 0.03% (95% CI: 0.00%, 0.06%) in Shanghai to 4.6% (95% CI: 3.3%, 5.9%) in Anhui province. We also found similar patterns for provincial variations in intensity of CHE and MI. Moreover, substantial provincial variations in income-related inequality and urban-rural gap existed across provinces. Eastern developed provinces in general had much lower inequality within them, compared with central and western provinces. Interpretation: Despite the great advances towards UHC in China, substantial provincial variations exist in financial protection across provinces. Policymakers should pay special attention to low-income households in central and western provinces. Provision of better financial protection for these vulnerable groups will be key to achieving UHC in China. Funding: This research was supported by the National Natural Science Foundation of China (Grant Number: 72074049) and the Shanghai Pujiang Program (2020PJC013).

Expanding outpatient benefits package can reduce diabetes-related avoidable hospitalizations.

Objective: To evaluate the policy effect of replacing hospitalization service with outpatient service and reducing diabetes-related avoidable hospitalizations by improving outpatient benefits package. Methods: A database of hospital discharge from 2015 to 2017 in City Z was used. All diabetic inpatient cases enrolled in Urban Employee Basic Medical Insurance were selected as the intervention group, and diabetic inpatient cases enrolled in Urban and Rural Resident Basic Medical Insurance were selected as the control group. The Difference-in-Difference model was used to analyze the effect of improving outpatient benefits package level of diabetes from 1800 yuan (about $252.82) to 2400 yuan (about $337.09) per capita per year on avoidable hospitalization rate, average hospitalization cost and average length of stay. Results: The avoidable hospitalization rate of diabetes mellitus decreased by 0.21 percentage points (P < 0.01), the average total cost of hospitalization increased by 7.89% (P < 0.01), and the average length of stay per hospitalization increased by 5.63% (P < 0.01). Conclusions: Improving the outpatient benefits package of diabetes can play a role in replacing hospitalization service with outpatient service, reducing diabetes-related avoidable hospitalizations, and reducing the disease burden and financial burden.

Understanding medical corruption in China: a mixed-methods study.

Medical corruption is a significant obstacle to achieving health-related Sustainable Development Goals. However, the understanding of medical corruption is limited, especially in developing countries. As the largest developing country, China is also plagued by medical corruption. By employing a mixed-methods design and combining data from three resources, this study attempts to examine patterns of medical corruption in China, explore its key drivers and investigate the perceived effectiveness of recent anti-corruption interventions. Using extracted data from 3546 cases on the China Judgments Online website between 2013 and 2019, we found that bribery, embezzlement and insurance fraud accounted for 68.1%, 22.8% and 9.1% of all medical corruption cases, respectively. Bribery was the major form of medical corruption. Approximately 80% of bribe-takers were healthcare providers, and most bribe-givers were suppliers of pharmaceuticals, medical equipment and consumables. Using a nationally representative household survey, we further found that the prevalence of informal payments from patients remained at a low level between 2011 and 2018. In 2018, only 0.4% of outpatients and 1.4% of inpatients reported that they had ever given 'red envelopes' to physicians in the past. Finally, we conducted interviews with 17 key informants to explore drivers of medical corruption and investigated the perceived effectiveness of recent anti-corruption interventions in China. Interview results showed that financial pressure and weak oversight were two main reasons for corrupt behaviours. Interview results also suggested that the anti-corruption campaign since 2012, the national volume-based procurement, and the special campaign against medical insurance fraud had reduced opportunities for medical corruption, implying China's positive progress in combating medical corruption. These findings hold lessons for anti-corruption interventions in China as well as other developing countries.

Trends and projections of universal health coverage indicators in China, 1993-2030: An analysis of data from four nationwide household surveys.

Background: Universal health coverage (UHC) is a core element of Sustainable Development Goals and has become a global healthcare priority. China has been committing to provide all citizens with affordable and equitable basic healthcare over past decades. However, progress towards UHC in China has not been comprehensively assessed. This study aims to comprehensively evaluate the progress towards UHC in China by examining trends in service coverage and financial protection from 1993 to 2018, and estimating the probability of achieving UHC targets by 2030. Methods: Following the framework proposed by World Health Organization and World Bank, we selected 12 prevention service indicators, 12 treatment service indicators, and two financial protection indicators to evaluate China's progress towards UHC. We used data from four nationally representative household surveys to assess the trends in service coverage and financial protection between 1993 and 2018, as well as their inequalities across subgroups. Meta-analysis was used to construct the composite prevention and treatment indices. The regression-based relative index of inequality was used to measure the income-related inequality of UHC indicators. Bayesian linear regression was conducted to predict progress towards UHC by 2030, and the probability of achieving UHC targets. Findings: Of the 24 service coverage indicators used in this study, most of them experienced improvements between 1993 and 2018. The composite prevention index increased from 65.6% (95% CI: 52.1%-77.9%) to 87.7% (95% CI: 81.8%-92.6%) and the composite treatment index increased from 57.1% (95% CI: 43.5%-70.1%) to 75.5% (95% CI: 66.6%-83.5%). The inequalities of service coverage experienced significant declines during this period. Based on our projections, most indicators except ones in the area of non-communicable diseases (NCD) will achieve the 80% coverage target by 2030, and the prevention and treatment indices will increase to 92.7% (95% CrI: 90.3%-94.7%) and 83.2% (95% CrI: 75.1%-88.8%) by then. However, we observed limited reductions in the incidences of catastrophic health expenditure and medical impoverishment. Inequalities in financial protection remained large in 2018. Interpretation: China had made significant progress in improving healthcare service coverage and reducing inequalities between 1993 and 2018. However, China faces great challenges in improving financial protection and controlling NCD on its path towards UHC. Establishment of a primary-healthcare-based integrated delivery system and provision of better financial protection for vulnerable population should be prioritized. Funding: None.

Trends in avoidable hospitalizations in a developed City in eastern China: 2015 to 2018.

OBJECTIVE: This study aimed to measure the avoidable hospitalization rate and the treatment cost per hospitalization in large cities of eastern China. METHODS: In this study, the hospital discharge data of all inpatients in the city from 2015 to 2018 were collected. In accordance with the organization for Economic Cooperation and Development (OECD) definition of avoidable hospitalizations, five diseases were selected as the measurement objects, including hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), as well as congestive heart failure (CHF). We described the avoidable hospitalization rate, average cost and length of stay for avoidable hospitalization cases. Linear probability model and log-linear model were used to control the basic characteristics and disease severity of patients, and to measure the trend of the avoidable hospitalization rate and expenditure of avoidable hospitalizations. RESULTS: From 2015 to 2018, the absolute number of avoidable hospitalizations in the city increased while fluctuating, which reached 125,372 in 2018. Among the five avoidable hospitalizations, the number of hospitalizations for diabetes increased continuously in the 4-year period. Congestive heart failure showed the most significant increase over the four years. Avoidable hospitalizations in the city have remained at a high level, while avoidable hospitalizations of hypertension and asthma fell to levels lower than those in 2015 in 2017 and 2018 after rising in 2016. The cost per hospitalization and length of stay per hospitalization decreased. CONCLUSIONS: Avoidable hospitalizations in the city remain at a high level, and more effective policies should be formulated to guide patients with avoidable hospitalizations, so as to more effectively exploit outpatient services and continuously improve the quality of primary health care services.

Understanding online dual practice of public hospital doctors in China: a mixed-methods study.

Telemedicine and telehealth hold promise for reducing access barriers, improving quality and containing medical costs. As Internet companies enter the healthcare market, a rising number of online healthcare platforms have emerged worldwide. In some countries like China, public hospital doctors are providing direct-to-consumer telemedicine services on these commercial platforms as independent providers. Such online service provision creates a new form of dual practice, which we refer to as 'online dual practice' in this study. Using a mixed-methods design, this study aims to investigate the prevalence of online dual practice, doctors' time allocation and motivations for engaging in it and its potential impacts on the health system in China. We use the web-crawled data from four leading online health platforms to examine the prevalence of online dual practice in China. Then we conduct in-depth interviews with 38 active doctors on these platforms to investigate their time allocation, motivations and perception regarding online service provision. We find that the nationwide prevalence of online dual practice in China reaches at least 16.5% in 2020 and that it is more common among senior public hospital doctors. Public hospital doctors mainly use small pockets of time during working hours and after-hours to render services on the platforms The five most commonly cited motivations for their engagement in online dual practice are efficiency improvement, personal control, career development, financial rewards and serving the patients. Interviewed doctors believe that their online service provision is conducive to increasing healthcare access and improving efficiency, but some also express their concerns about the quality of care. Further analysis shows that the impact of online dual practice on health system performance remains an open question and regulatory policies on it should be health-system specific.

Trends in Smoking Prevalence and Intensity between 2010 and 2018: Implications for Tobacco Control in China.

BACKGROUND: China is the world's largest producer and consumer of cigarettes. Since 2010, the Chinese government has implemented many policies to combat the tobacco epidemic, yet little is known about their overall impacts. This study aims to investigate the trends in smoking prevalence and intensity between 2010 and 2018. METHODS: We use five waves of data from China Family Panel Studies (CFPS), a nationally representative survey, to examine the trends in smoking prevalence and intensity. We use the chi-square test and t-test to examine differences across waves. Binary logistic regressions and linear regressions are applied to examine the association between smoking behaviors and risk factors. RESULTS: The current smoking prevalence dropped from 30.30% in 2010 (90% CI 29.47-31.31) to 28.69% (90% CI 27.69-29.69) in 2018. As for smoking intensity, the average daily cigarettes consumption decreased steadily from 16.96 cigarettes (90% CI 16.55-17.36) in 2010 to 15.12 cigarettes (90% CI 15.07-15.94) in 2018. Smoking risk factors for men included marriage status, education level, employment status, alcohol consumption, and physical activities. The smoking risk was higher for women with a lower education level, lower household income, unemployment status, and alcohol consumption behavior. CONCLUSIONS: Our study shows declined trends in both smoking prevalence and intensity between 2010 and 2018, suggesting some positive progress in tobacco control in China. Nonetheless, to achieve the goal of reducing smoking prevalence among people aged 15 and above to less than 20% by 2030, the Chinese government needs to take stronger anti-tobacco measures.

How do Chinese people perceive their healthcare system? Trends and determinants of public satisfaction and perceived fairness, 2006-2019.

BACKGROUND: The public's perception of the health system provides valuable insights on health system performance and future directions of improvement. While China's health care reform was a response to people's discontent in the health care system due to the lack of accessibility and affordability, little is known on changes in public perception of China's health system. This paper examines trends in public perception of the health system between 2006 and 2019 and assesses determinants of public perception in China's health system. METHODS: Seven waves of the China Social Survey, a nationally representative survey, were used to examine trends in public satisfaction with health care and perceived fairness in health care. Chi-square tests were used to examine differences across waves. Logistic regression models were used to explore determinants of public perception, including variables on sociodemographic characteristics, health system characteristics, and patient experience. RESULTS: Satisfaction with health care increased from 57.76% to 77.26% between 2006 and 2019. Perceived fairness in health care increased from 49.79% to 72.03% during the same period. Both indicators showed that the major improvement occurred before 2013. Sociodemographic characteristics are weakly associated with public perception. Financial protection and perceived medical safety are strongly associated with public perception, while accessibility is weakly associated with public perception. Patient experience such as perceived affordability and quality in the last medical visit are strongly associated with public perception of the health care system, while the accessibility of the last medical visit shows no impacts. CONCLUSION: Public satisfaction on health care and perceived fairness in health care in China improved over 2006-2019. The main improvement occurred in accordance with huge financial investments in public health insurance before 2013. Financial protection and perceived quality play significant roles in determining public perception, whereas accessibility and sociodemographic characteristics have limited influence on people's perception of China's health system. To achieve higher satisfaction and a higher sense of fairness in health care, China's health system needs to continue its reforms on hospital incentives and integrated delivery system to control health expenditure and improve health care quality.

Hospital response to a case-based payment scheme under regional global budget: The case of Guangzhou in China.

Both developed and developing countries have been searching for effective provider payment methods to control health expenditure inflation. In January 2018, Guangzhou city in Southern China initiated an innovative case-based payment method for inpatient care under the framework of the regional global budget, called the Diagnosis-Intervention Packet (DIP). Contrary to the usual practice of the case-based payment, the DIP payment scheme includes a price adjustment mechanism through which the actual reimbursement for each case is determined ex post. By employing the difference-in-difference method and data from Beijing and Guangzhou, we evaluate the effects of the DIP payment on medical expenditures and provider behaviors. We find that total health expenditures per case have decreased by 3.5%, which is mainly driven by a substantial decrease in drug expenditures. It suggests that the DIP payment reform achieved a short-term success in slowing down the growth of health expenditures. However, the average point volume per case for local inpatients with social health insurance coverage has increased by more than 3%, primarily due to an increasing likelihood of performing at least one procedure. We also find suggestive evidence of up-coding. All these results suggest that healthcare providers have taken strategic behaviors in response to the DIP payment. These findings hold lessons for the ongoing payment reforms in China and other countries.

Health service underutilization and its associated factors for chronic diseases patients in poverty-stricken areas in China: a multilevel analysis.

BACKGROUND: Underutilization of health services among chronic non-communicable disease sufferers, especially for hypertension (HBP) and diabetes mellitus (DM), was considered as a significant contributing factor to substantial cases in terms of both avoidable morbidity and mortality. However, evidence on health services underutilization and its associated factors in poverty-stricken areas remain scarce based on previous literature. This study aims to describe health services underutilization for people diagnosed with chronic diseases in impoverished regions and to identify its associated factors, which are expected to provide practical implications for the implementations of interventions tailored to the specific needs of disadvantaged residents in rural China to achieve effective utilization of health services in a timely manner. METHODS: Data were collected from a cross-sectional survey conducted through face-to-face interviews among 2413 patients from six counties in rural central China in 2019. The Anderson behavioral model was adopted to explore the associated factors. A two-level logistic model was employed to investigate the association strengths reflected by adjusted odds ratios (AOR) and 95% confidence intervals in forest plots. RESULTS: On average, 17.58% of the respondents with HBP and 14.87% with DM had experienced health services underutilization during 1 month before the survey. Multilevel logistic regression indicated that predisposing factors (age), enabling factors (income and a regular source of care), and need factors (self-reported health score) were the common predictors of health service underutilization both for hypertensive and diabetic patients in impoverished areas, among which obtaining a regular source of care was found to be relatively determinant as a protective factor for health services underutilization after controlling for other covariates. CONCLUSIONS: Our results suggested that the implementation of a series of comprehensive strategies should be addressed throughout policy-making procedures to improve the provision of regular source of care as a significant determinant for reducing health services underutilization, thus ultimately achieving equal utilization of health services in impoverished regions, especially among chronic disease patients. Our findings are expected to provide practical implications for other developing countries confronted with similar challenges resulting from underdeveloped healthcare systems and aging population structures.

A Tale of Transition: Trends of Catastrophic Health Expenditure and Impoverishment in Urban China, 1986-2009.

From 1986 to 2009, China's health system reform first adopted a market-oriented approach and later reemphasized the role of the government starting from 2002. China's oscillating health care financing policies present us a unique opportunity to examine the consequences of government-led financing and market-oriented financing measures. This study uses the Urban Household Survey, a diary data in China that covers the period of 1986 to 2009, to examine the long-run trends in the incidence and intensity of catastrophic health expenditure and medical impoverishment. Four major findings emerge. First, the incidence and intensity of catastrophic health expenditure in urban Chinese households increased rapidly between 1986 and 2002, whereas they stabilized after 2002. Second, the incidence of medical impoverishment and its depth in the poverty gap remained stable before 2002 and decreased rapidly after 2002. Third, income and regional inequality in measures of catastrophic health expenditure widened from 1986 to 2002. They narrowed in the 2000s but remain wide. Fourth, income and regional inequality in medical impoverishment remained unchanged between 1986 and 2002 and narrowed substantially after 2002. All these results suggest that China's two cycles of health care reform generated significantly different outcomes in financial protection, holding lessons for the ongoing health care reform in China and other countries.

Trends in access to health services, financial protection and satisfaction between 2010 and 2016: Has China achieved the goals of its health system reform?

Guided by the principle of universal health coverage, China began its complex health system reform in 2009. Using data from the China Family Panel Studies (CFPS), this study assesses trends in healthcare utilization, financial protection, and satisfaction between 2010 and 2016. We use difference-in-means tests and regression analysis to evaluate overall trends and compare subsample results by urban/rural residence and income quartiles to examine changes in inequity. Our results show that China has achieved substantial improvements in access to healthcare services and financial protection since the health system reform in 2009. First, China has experienced a substantial increase in both inpatient and outpatient care utilization between 2010 and 2016. Second, people receive better financial protection by measures of health insurance coverage, inpatient reimbursement rate, the likelihood of incurring catastrophic health expenditure, and the likelihood of medical impoverishment. Third, inequity in financial protection by income quartiles has significantly decreased, though poorer groups remain more vulnerable. However, we do not observe a concurrent increase in satisfaction towards the health system. We also find that people are more willing to seek medical services in hospitals rather than primary care institutions. All these results suggest that China's ongoing health system reform should pay more attention to establishing a tiered health delivery system, strengthening financial protection for the poor, and increasing responsiveness to rising expectations.