Strengthening of Traditional Chinese Medicine in the Health System Reform: Effect on Health Outcomes and Financial Protection.

BACKGROUND: The challenges of modern medicine in addressing chronic diseases necessitate a shift of attention towards traditional medicine (TM) and other supplementary care systems. China has prioritized the strengthening of traditional Chinese medicine (TCM) in the health system reform since 2009. This study sought to assess the effects of the reform on TCM and the resultant effect of a strengthened TCM on health outcomes and financial protection. METHODS: Longitudinal data were obtained from the China Statistical Yearbook, China Health Statistical Yearbook, China Population Statistical Yearbook, and Statistical Extract of Traditional Chinese Medicine in 31 provinces of mainland China between 2002 and 2016. Dependent variables included health outcomes measured by age-standardized excess mortality and life expectancy at birth and financial protection measured by the proportion of health expenses in total consumption expenses. The independent variables consisted of the number and proportion of TCM physicians. The fixed effects (FEs) models were established to identify the effect of the independent variables on outcomes. RESULTS: From 2009 to 2016, the number and proportion of TCM physicians increased from 22 to 36 physicians per 100,000 population and from <12% to >15%, respectively. The changes were more rapid and higher than that in the period before the reform. An increase of 1 TCM physician per 100,000 population was associated with a decrease of 1.944 excess deaths, a 5.84-day increase in male life expectancy, and a decrease of 0.051% of health expenses among both urban and rural residents. An increase in proportion of 1% of TCM physicians was associated with a decrease of 5.097 excess deaths, a 17.52-day increase of life expectancy (both genders), an increase of 21.535-day in life expectancy (males) per 100,000 population, and a decrease of 0.082% of health expenses among rural residents. CONCLUSION: During China's health system reform, the increased physician number has strengthened TCM. Higher TCM physician supply was associated with improved health outcomes and financial protection, which implies that the reform may have important implications on health system performance in China.

Different impacts of the zero-markup drug policy on county general and traditional Chinese medicine hospitals: evidence from Shandong province, China.

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. Meanwhile, some unintended consequences were also recognized through the analysis, such as the decline of the utilization of the TCM.

China's private institutions for the education of health professionals: a time-series analysis from 1998 to 2012.

BACKGROUND: Public institutions have been the major provider of education for health professionals in China for most of the twentieth century. In the 1990s, the Chinese government began to encourage the establishment of private education institutions, which have been steadily increasing in numbers over the past decade. However, there is a lack of authoritative data on these institutions and little has been published in international journals on the current status of private education of health professionals in China. In light of this knowledge gap, we performed a quantitative analysis of private institutions in China that offer higher education of health professionals. METHODS: Using previously unreleased national data provided by the Ministry of Education of China, we conducted time-series and descriptive analyses to study the scale, structure and educational resources from 1998 to 2012 of private institutions for health professional education. RESULTS: The number of private institutions that educate health professionals increased from two in 1999 to 123 in 2012. Private institutions displayed an average annual growth rate of 44.2% for enrolment, 59.0% for the number of students and 53.3% for the number of graduates. In 2012, nursing, clinical medicine and traditional Chinese medicine had the most students (37.2%, 32.8% and 8.9% respectively), representing 78.9% of all students in these institutions. Ninety-seven private institutions located in the more economically advantaged eastern and central China and only 26 ones were in the less economically advantaged western China, respectively turning out 85.2% and 14.8% of health professional graduates. There were less educational resources, such as the number of faculty members, physical space and assets, at private institutions than at public institutions. CONCLUSIONS: Private institutions for the education of health professionals have emerged quickly in China, contributing to the demand for health professionals that exceeds what public institutions are able to offer. At the same time, the imbalance of geographical distribution and poor educational resources of private institutions are of concern. It may be of utmost importance to enhance administration and supervision to better regulate private institutions and their development plans. Future studies may be needed to better examine the effects of private institutions on the production and allocation of health workers.

The Structure and Effectiveness of Health Systems: Exploring the Impact of System Integration in Rural China.

INTRODUCTION: Facing the challenges of aging populations, increasing chronic diseases prevalence and health system fragmentation, there have been several pilots of integrated health systems in China. But little is known about their structure, mechanism and effectiveness. The aim of this paper is to analyze health system integration and develop recommendations for achieving integration. METHOD: Huangzhong and Hualong counties in Qinghai province were studied as study sites, with only Huangzhong having implemented health system integration. Questionnaires, interviews, and health insurance records were sources of data. Social network analysis was employed to analyze integration, through structure measurement and effectiveness evaluation. RESULTS: Health system integration in Huangzhong is higher than in Hualong, so is system effectiveness. The patient referral network in Hualong has more "leapfrog" referrals. The information sharing networks in both counties are larger than the other types of networks. The average distance in the joint training network of Huangzhong is less than in Hualong. Meanwhile, there are deficiencies common to both systems. CONCLUSION: Both county health systems have strengths and limitations regarding system integration. The use of medical consortia in Huangzhong has contributed to system effectiveness. Future research might consider alternative more context specific models of health system integration.