Price negotiation and pricing of anticancer drugs in China: An observational study.

BACKGROUND: While China has implemented reimbursement-linked drug price negotiation annually since 2017, emphasizing value-based pricing to achieve a value-based strategic purchase of medical insurance, whether drug prices became better aligned with clinical value after price negotiation has not been sufficiently established. This study aimed to assess the changes in prices and their relationship with the clinical value of anticancer drugs after the implementation of price negotiations in China. METHODS AND FINDINGS: In this observational study, anticancer drug indications that were negotiated successfully between 2017 and 2022 were identified through National Reimbursement Drug Lists (NRDL) of China. We excluded extensions of indications for drugs already listed in the NRDL, indications for pediatric use, and indications lacking corresponding clinical trials. We identified pivotal clinical trials for included indications by consulting review reports or drug labels issued by the Center for Drug Evaluation, National Medical Products Administration. We calculated treatment costs as outcome measures based on publicly available prices and collected data on clinical value including safety, survival, quality of life, and overall response rate (ORR) from publications of pivotal clinical trials. The associations between drug costs and clinical value, both before and after negotiation, were analyzed using regression analyses. We also examined whether price negotiation has led to a reduction in the variation of treatment costs for a given value. We included 103 anticancer drug indications, primarily for the treatment of blood cancer, lung cancer, and breast cancer, with 76 supported by randomized controlled trials and 27 supported by single-arm clinical trials. The median treatment costs over the entire sample have been reduced from US$34,460.72 (interquartile range (IQR): 19,990.49 to 55,441.66) to US$13,688.79 (IQR: 7,746.97 to 21,750.97) after price negotiation (P < 0.001). Before price negotiation, each additional month of survival gained was associated with an increase in treatment costs of 3.4% (95% confidence interval (CI) [2.1, 4.8], P < 0.001) for indications supported by randomized controlled trials, and a 10% increase in ORR was associated with a 6.0% (95% CI [1.6, 10.3], P = 0.009) increase in treatment costs for indications supported by single-arm clinical trials. After price negotiation, the associations between costs and clinical value may not have changed significantly, but the variation of drug costs for a given value was reduced. Study limitations include the lack of transparency in official data, missing data on clinical value, and a limited sample size. CONCLUSIONS: In this study, we found that the implementation of price negotiation in China has led to drug pricing better aligned with clinical value for anticancer drugs even after substantial price reductions. The achievements made in China could shed light on the price regulation in other countries, particularly those with limited resources and increasing drug expenditures.

Is low-dose computed tomography for lung cancer screening conveniently accessible in China? A spatial analysis based on cross-sectional survey.

BACKGROUND: Regular Low-Dose Computed Tomography (LDCT) for lung cancer high-risk population has been proved to improve health outcomes and relieve disease burden efficiently for both individual and society. With geographical impedance becoming the major barrier preventing patients from getting timely healthcare service, this study incorporated health seeking behavior in estimating spatial accessibility of relative scarce LDCT resource in China, thus to provide real-world evidence for future government investment and policy making. METHODS: Taking Sichuan Province in southwest China as the study area, a cross-sectional survey was first carried out to collect actual practice and preferences for seeking LDCT services. Using Computed Tomography (CT) registration data reported by owner institutions representing LDCT services capacity, and grided town-level high-risk population as demand, the Nearest Neighbor Method was then utilized to calculate spatial accessibility of LDCT services. RESULTS: A total of 2,529 valid questionnaires were collected, with only 34.72% of the high-risk populations (746 individuals) followed the recommended annual screening. Participants preferred to travel to municipal-level and above institutions within 60 min for LDCT services. Currently, every thousand high-risk populations own 0.0845 CT scanners in Sichuan Province, with 96.95% able to access LDCT within 60 min and over half within 15 min. Urban areas generally showed better accessibility than rural areas, and the more developed eastern regions were better than the western regions with ethnic minority clusters. CONCLUSIONS: Spatial access to LDCT services is generally convenient in Sichuan Province, but disparity exists between different regions and population groups. Improving LDCT capacity in county-level hospitals as well as promoting health education and policy guidance to the public can optimize efficiency of existing CT resources. Implementing mobile CT services and improving rural public transportation may alleviate emerging disparities in accessing early lung cancer detection.

Revealing spatiotemporal inequalities, hotspots, and determinants in healthcare resource distribution: insights from hospital beds panel data in 2308 Chinese counties.

BACKGROUND: Ensuring universal health coverage and equitable access to health services requires a comprehensive understanding of spatiotemporal heterogeneity in healthcare resources, especially in small areas. The absence of a structured spatiotemporal evaluation framework in existing studies inspired us to propose a conceptual framework encompassing three perspectives: spatiotemporal inequalities, hotspots, and determinants. METHODS: To demonstrate our three-perspective conceptual framework, we employed three state-of-the-art methods and analyzed 10 years' worth of Chinese county-level hospital bed data. First, we depicted spatial inequalities of hospital beds within provinces and their temporal inequalities through the spatial Gini coefficient. Next, we identified different types of spatiotemporal hotspots and coldspots at the county level using the emerging hot spot analysis (Getis-Ord Gi* statistics). Finally, we explored the spatiotemporally heterogeneous impacts of socioeconomic and environmental factors on hospital beds using the Bayesian spatiotemporally varying coefficients (STVC) model and quantified factors' spatiotemporal explainable percentages with the spatiotemporal variance partitioning index (STVPI). RESULTS: Spatial inequalities map revealed significant disparities in hospital beds, with gradual improvements observed in 21 provinces over time. Seven types of hot and cold spots among 24.78% counties highlighted the persistent presence of the regional Matthew effect in both high- and low-level hospital bed counties. Socioeconomic factors contributed 36.85% (95% credible intervals [CIs]: 31.84-42.50%) of county-level hospital beds, while environmental factors accounted for 59.12% (53.80-63.83%). Factors' space-scale variation explained 75.71% (68.94-81.55%), whereas time-scale variation contributed 20.25% (14.14-27.36%). Additionally, six factors (GDP, first industrial output, local general budget revenue, road, river, and slope) were identified as the spatiotemporal determinants, collectively explaining over 84% of the variations. CONCLUSIONS: Three-perspective framework enables global policymakers and stakeholders to identify health services disparities at the micro-level, pinpoint regions needing targeted interventions, and create differentiated strategies aligned with their unique spatiotemporal determinants, significantly aiding in achieving sustainable healthcare development.

Satisfaction with clinical pathway implementation versus job performance of clinicians: empirical evidence on the mediating role of work engagement from public hospitals in Sichuan, China.

BACKGROUND: The job performance of clinicians is a clear indicator of both hospital capacity and the level of hospital service. It plays a crucial role in maintaining the effectiveness and quality of medical care. Clinical pathways are a systematic method of quality improvement successfully recommended by broader healthcare systems. Since clinicians play a key role in implementing clinical pathways in public hospitals, this study aims to investigate the effect of the satisfaction of clinicians in public hospitals with clinical pathway implementation on their job performance. METHODS: A cross-sectional study design was used. Questionnaires were administered online. A total of 794 clinicians completed the questionnaires in seven tertiary public hospitals in Sichuan Province, China, of which 723 were valid for analysis. Questionnaires contained questions on social demographic characteristics, satisfaction with clinical pathway implementation, work engagement, and job performance. Structural Equation Model (SEM) was used to test the hypotheses. RESULTS: The satisfaction of clinicians in public hospitals with clinical pathway implementation was significantly positively correlated with work engagement (r = 0.570, P < 0.01) and job performance (r = 0.522, P < 0.01). A strong indirect effect of clinicians' satisfaction with clinical pathway implementation on job performance mediated by work engagement was observed, and the value of this effect was 0.383 (boot 95%CI [0.323, 0.448]). CONCLUSION: The satisfaction of clinicians in public hospitals with clinical pathway implementation not only directly influences their job performance, but also indirectly affects it through the mediating variable of work engagement. Therefore, managers of public hospitals need to pay close attention to clinicians' evaluation and perception of the clinical pathway implementation. This entails taking adequate measures, such as providing strong organizational support and creating a favorable environment for the clinical pathway implementation. Additionally, focusing on teamwork to increase clinicians' satisfaction can further enhance job performance. Furthermore, managers should give higher priority to increasing employees' work engagement to improve clinicians' job performance.

Impact of clinical pathway implementation satisfaction, work engagement, and hospital-patient relationship on quality of care in Chinese nurses.

AIMS: This study aimed to investigate how clinical pathway implementation satisfaction, work engagement, and hospital-patient relationship impact the quality of care that is provided by nurses in public hospitals. BACKGROUND: Clinical pathways are recommended as a form of quality improvement by broader healthcare systems and are widely used in the world. Nurses are the most involved group of healthcare professionals in the implementation of clinical pathways in public hospitals. So, it is important to investigate how their satisfaction with the process affects the quality of care they provide and influencing factors. METHODS: This descriptive cross-sectional study surveyed nurses practicing across seven tertiary public hospitals in Sichuan Province, China, online. The survey consisted of a questionnaire for the general characteristics of the participants and four Chinese maturity scales validated by previous studies: clinical pathway implementation satisfaction scale, work engagement scale, hospital-patient relationship perception scale, and quality of care scale. The bootstrap method was used to test a moderated mediation model using Hayes' PROCESS macro models 4 and 8. We followed STROBE guidelines to prepare the study report. RESULTS: A total of 880 nurses filled out the questionnaires, 821 of which were regarded as valid. Clinical pathway implementation satisfaction had a positive effect on quality of care (B = 0.873, P < 0.001). Work engagement played a mediation role between nurses' clinical pathway implementation satisfaction and the quality of care (effect = 0.080, Boot 95% CI = [0.023, 0.142]). This mediation model was moderated by the hospital-patient relationship (P < 0.01). CONCLUSION: Clinical pathway implementation satisfaction may enhance the quality of care by work engagement of nurses. Moreover, a good hospital-patient relationship can enhance the positive impact of nurses' satisfaction on work engagement and health service quality. IMPLICATIONS FOR NURSING AND NURSING POLICY: Public hospital managers need to pay attention to nurses' evaluation of and perceptions toward clinical pathway implementation and then take corresponding measures to improve their satisfaction to enhance the quality of care. At the same time, the government, society, and hospitals also need to foster good hospital-patient relationships to ensure that nurses have a high level of work engagement that aids in providing high-quality care services.

Understanding Factors Influencing Geographic Variation in Healthcare Expenditures: A Small Areas Analysis Study.

Dramatic geographic variations in healthcare expenditures were documented by developed countries, but little is known about such variations under China's context, and what causes such variations. This study aims to examine variations of healthcare expenditures among small areas and to determine the associations between demand-, supply-factors, and per capita inpatient expenditures. This cross-sectional study utilized hospital discharge data aggregated within delineated hospital service areas (HSAs) using the small-area analysis approach. Linear multivariate regression modeling with robust standard errors was used to estimate the sources of variation of per capita inpatient expenditures across HSAs covering the years 2017 to 2019; the Shapley value decomposition method was used to measure the respective contributions of demand-, supply-side to such variations. Among 149 HSAs, demand factors explained most of the (87.4%) overall geographic variation among HSAs. With each 1% increase in GDP per capita and urbanization rate was associated with 0.099% and 0.9% increase in inpatient expenditure per capita, respectively, while each 1% increase in the share of females and the unemployment rate was associated with a 0.7% and 0.4% reduction in the per capita inpatient expenditures, respectively. In supply-side, for every 1 increase in hospital beds per 1000 population, the per capita inpatient expenditures rose by 2.9%, while with every 1% increase in the share of private hospitals, the per capita inpatient expenditures would decrease by 0.4%. With Herfindahl-Hirschman Index decrease 10%, the per capita inpatient expenditures would increase 1.06%. This study suggests demand-side factors are associated with large geographic variation in per capita inpatient expenditures among HSAs, while supply-side factors played an important role. The evaluation of geographic variations in per capita inpatient expenditures as well as its associated factors have great potential to provide an indirect approach to identify possibly existing underutilized or overutilized healthcare procedures.

Association of Launch Price and Clinical Value With Reimbursement Decisions for Anticancer Drugs in China.

BACKGROUND: The potential role played by launch price and clinical value in reimbursement decisions has not been sufficiently established in China. This study aimed to investigate the association of launch price and clinical value with reimbursement decisions for anticancer drugs after the implementation of reimbursement-linked price negotiation in China. METHODS: Anticancer drugs approved by the National Medical Products Administration (NMPA) of China from January 2017 to June 2022 were eligible for inclusion. Approval and reimbursement dates of included drug indications were retrieved from publicly available resources. We collected measures of clinical value, including survival, quality of life (QoL), and overall response rate from pivotal clinical trials and calculated treatment price at launch. Univariate and multivariate Cox proportional hazards models were employed to estimate the association between launch price, clinical value, and reimbursement decisions of anticancer drugs in China. RESULTS: The median reimbursement lag was 579 days (interquartile range [IQR]: 402-936) for 93 indications supported by randomized controlled trials and 637 days (IQR: 373-858) for 42 indications supported by single-arm clinical trials. Reimbursement was granted to 60 (65%) and 23 (55%) indications supported by randomized controlled and single-arm clinical trials, respectively. The launch price of anticancer drugs was not associated with reimbursement decisions in multivariate regression analyses. Indications supported by randomized controlled trials with higher clinical value were more likely to be reimbursed (hazard ratio [HR] for survival=1.07, 95% CI: 1.00-1.15, P=.037), while the overall response rate of indications supported by single-arm clinical trials was not associated with the likelihood of being reimbursed (HR=2.09, 95% CI: 0.14-32.28, P=.595). CONCLUSION: The launch price of anticancer drugs may not have a significant impact on reimbursement decisions, while the implementation of reimbursement-linked price negotiation in China has prioritized anticancer drugs with higher clinical value, but only for indications supported by randomized controlled trials. Efforts are needed to prioritize indications supported by single-arm clinical trials that have higher value during the process of price negotiation.

Doctors' Personal Preference and Adoption of Mobile Apps to Communicate with Patients in China: Qualitative Study.

BACKGROUND: Different kinds of mobile apps are used to promote communications between patients and doctors. Studies have investigated patients' mobile app adoption behavior; however, they offer limited insights into doctors' personal preferences among a variety of choices of mobile apps. OBJECTIVE: This study aimed to investigate the nuanced adoption behaviors among doctors in China, which has a robust adoption of mobile apps in health care, and to explore the constraints influencing their selection of specific mobile apps. This paper addressed 3 research questions: (1) Which doctors opt to adopt mobile apps to communicate with patients? (2) What types of mobile apps do they choose? (3) To what degree do they exercise personal choice in adopting specific mobile apps? METHODS: We used thematic content analysis of qualitative data gathered from semistructured interviews with 11 doctors in Hangzhou, which has been recognized for its advanced adoption of mobile technology in social services, including health care services. The selection of participants was purposive, encompassing diverse departments and hospitals. RESULTS: In total, 5 themes emerged from the data analysis. First, the interviewees had a variety of options for communicating with patients via mobile apps, with the predominant ones being social networking apps (eg, WeChat) and medical platforms (eg, Haodf). Second, all interviewees used WeChat to facilitate communication with patients, although their willingness to share personal accounts varied (they are more likely to share with trusty intermediaries). Third, fewer than half of the doctors adopted medical platforms, and they were all from tertiary hospitals. Fourth, the preferences for in-person, WeChat, or medical platform communication reflected the interviewees' perceptions of different patient cohorts. Lastly, the selection of a particular kind of mobile app was significantly influenced by the doctors' affiliation with hospitals, driven by their professional obligations to fulfill multiple tasks assigned by the hospitals or the necessity of maintaining social connections with their colleagues. CONCLUSIONS: Our findings contribute to a nuanced understanding of doctors' adoption behavior regarding specific types of mobile apps for patient communication, instead of addressing such adoption behavior of a wide range of mobile apps as equal. Their choices of a particular kind of app were positioned within a social context where health care policies (eg, limited funding for public hospitals, dominance of public health care institutions, and absence of robust referral systems) and traditional culture (eg, trust based on social connections) largely shape their behavioral patterns.

Heterogeneous effects of hospital competition on inpatient quality: an analysis of five common diseases in China.

BACKGROUND: Many countries has introduced pro-competition policies in the delivery of healthcare to improve medical quality, including China. With the increasing intensity of competition in China's healthcare market, there are rising concerns among policymakers about the impact of hospital competition on quality. This study investigated heterogeneous effects of hospital competition on inpatient quality. METHODS: We analyzed the inpatient discharge dataset and selected chronic obstructive pulmonary disease (COPD), ischemic stroke, pneumonia, hemorrhagic stroke, and acute myocardial infarction (AMI) as representative diseases. A total of 561,429 patients in Sichuan Province in 2017 and 2019 were included. The outcomes of interest were in-hospital mortality and 30-day unplanned readmissions. The Herfindahl-Hirschman Index was calculated using predicted patient flows to measure hospital competition. To address the spatial correlations of hospitals and the structure of the dataset, the multiple membership multiple classification model was employed for analysis. RESULTS: Amid intensifying competition in the hospital market, our study discerned no marked statistical variance in the risk of inpatient quality across most diseases examined. Amplified competition exhibited a positive correlation with heightened in-hospital mortality for both COPD and pneumonia patients. Elevated competition escalated the risk of 30-day unplanned readmissions for COPD patients, while inversely affecting the risk for AMI patients. CONCLUSIONS: There is the heterogeneous impact of hospital competition on quality across various diseases in China. Policymakers who intend to leverage hospital competition as a tool to enhance healthcare quality must be cognizant of the possible influences of it.

Public Heterogeneous Preferences for Low-Dose Computed Tomography Lung Cancer Screening Service Delivery in Western China: A Discrete Choice Experiment.

BACKGROUND: Lung cancer screening (LCS) with low-dose computed tomography (LDCT) is an efficient method that can reduce lung cancer mortality in high-risk individuals. However, few studies have attempted to measure the preferences for LDCT LCS service delivery. This study aimed to generate quantitative information on the Chinese population's preferences for LDCT LCS service delivery. METHODS: The general population aged 40 to 74 in the Sichuan province of China was invited to complete an online discrete choice experiment (DCE). The DCE required participants to answer 14 discrete choice questions comprising five attributes: facility levels, facility ownership, travel mode, travel time, and out-of-pocket cost. Choice data were analyzed using mixed logit and latent class logit (LCL) models. RESULTS: The study included 2529 respondents, with 746 (29.5%) identified as being at risk for lung cancer. Mixed logit model (MLM) analysis revealed that all five attributes significantly influenced respondents' choices. Facility levels had the highest relative importance (44.4%), followed by facility ownership (28.1%), while out-of-pocket cost had the lowest importance (6.4%). The at-risk group placed relatively more importance on price and facility ownership compared to the non-risk group. LCL model identified five distinct classes with varying preferences. CONCLUSION: This study revealed significant heterogeneity in preferences for LCS service attributes among the Chinese population, with facility level and facility ownership being the most important factors. The findings underscore the need for tailored strategies targeting different subgroup preferences to increase screening participation rates and improve early detection outcomes.

List prices and clinical value of anticancer drugs in China, Japan, and South Korea: a retrospective comparative study.

Background: High prices of anticancer drugs have raised concerns due to their financial impact on patients and healthcare systems. This study aimed to assess the initial and latest list prices and clinical value of reimbursed anticancer drugs in China, Japan, and South Korea. Methods: We identified anticancer drugs newly approved by the National Medical Products Administration of China from January 2012 to June 2022, and by the Pharmaceuticals and Medical Devices Agency of Japan and the Ministry of Food and Drug Safety of South Korea up until June 2022. We compared initial and latest treatment prices between countries and assessed clinical value using patients' survival, quality of life (QoL), and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). We calculated Spearman rank correlation coefficients of treatment prices with clinical value for individual countries and employed regression analyses to investigate whether the relationship between prices and clinical value was modified by the country setting. Findings: Our cohort included 91 anticancer drug indications, with 60 listed for reimbursement in China, 91 in Japan, and 87 in South Korea. Median treatment prices were highest in Japan, followed by South Korea, and lowest in China, both for initial prices (US$64082 vs. US$45529 vs. US$19144, p < 0.0001) and latest prices (US$50859 vs. US$31611 vs. US$18666, p < 0.0001). Over time, China (ß = -0.047, p < 0.0001) and South Korea (ß = -0.049, p < 0.0001) witnessed more significant price reductions compared to Japan (ß = -0.013, p = 0.011). The correlations between both initial and latest treatment prices and clinical value (QoL and ESMO-MCBS) were more significant and stronger in China and South Korea than in Japan, although Japan exhibited slightly stronger correlations in terms of survival compared to China and South Korea. The relationship between clinical value and treatment prices may not be modified by the country setting. Interpretation: In comparison, South Korea's list prices and their correlations with clinical value appear reasonable. Policymakers in Japan could enhance efficiency by controlling prices and aligning them with clinical value, while China would need to take substantial steps to expand anticancer drug coverage. Funding: National Natural Science Foundation of China (72374149 and 72074163), and China Center for South Asian Studies, Sichuan University.

Spatial Access to Continuous Maternal and Perinatal Health Care Services in Low-Resource Settings: Cross-Sectional Study.

BACKGROUND: Maternal and perinatal health are fundamental to human development. However, in low-resource settings such as sub-Saharan Africa (SSA), significant challenges persist in reducing maternal, newborn, and child mortality. To achieve the targets of the sustainable development goal 3 (SDG3) and universal health coverage (UHC), improving access to continuous maternal and perinatal health care services (CMPHS) has been addressed as a critical strategy. OBJECTIVE: This study aims to provide a widely applicable procedure to illuminate the current challenges in ensuring access to CMPHS for women of reproductive age. The findings are intended to inform targeted recommendations for prioritizing resource allocation and policy making in low-resource settings. METHODS: In accordance with the World Health Organization guidelines and existing literature, and taking into account the local context of CMPHS delivery to women of reproductive age in Mozambique, we first proposed the identification of CMPHS as the continuum of 3 independent service packages, namely antenatal care (ANC), institutional delivery (ID), and postnatal care (PNC). Then, we used the nearest-neighbor method (NNM) to assess spatial access to each of the 3 service packages. Lastly, we carried out an overlap analysis to identify 8 types of resource-shortage zones. RESULTS: The median shortest travel times for women of reproductive age to access ANC, ID, and PNC were 2.38 (IQR 1.38-3.89) hours, 3.69 (IQR 1.87-5.82) hours, and 4.16 (IQR 2.48-6.67) hours, respectively. Spatial barriers for women of reproductive age accessing ANC, ID, and PNC demonstrated large variations both among and within regions. Maputo City showed the shortest travel time and the best equity within the regions (0.46, IQR 0.26-0.69 hours; 0.74, IQR 0.47-1.04 hours; and 1.34, IQR 0.83-1.85 hours, respectively), while the provinces of Niassa (4.07, IQR 2.41-6.63 hours; 18.20, IQR 11.67-24.65 hours; and 7.69, IQR 4.74-13.05 hours, respectively) and Inhambane (2.69, IQR 1.49-3.91 hours; 4.43, IQR 2.37-7.16 hours; and 10.76, IQR 7.73-13.66 hours, respectively) lagged behind significantly in both aspects. In general, more than 51% of the women of reproductive age, residing in 83.25% of Mozambique's land area, were unable to access any service package of CMPHS in time (within 2 hours), while only about 21%, living in 2.69% of Mozambique's land area, including Maputo, could access timely CMPHS. CONCLUSIONS: The spatial accessibility and equity of CMPHS in Mozambique present significant challenges in achieving SDG3 and UHC, especially in the Inhambane and Niassa regions. For Inhambane, policy makers should prioritize the implementation of a decentralization allocation strategy to increase coverage and equity through upgrading existing health care facilities. For Niassa, the cultivation of well-trained midwives who can provide door-to-door ANC and PNC at home should be prioritized, with an emphasis on strengthening communities' engagement. The proposed 2-step procedure should be implemented in other low-resource settings to promote the achievement of SDG3.

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.

Analysis on the development and equity trends of health institutions in China:A research per-spective based on adjusted population and geographical area / 中国卫生政策研究

Objective: To analyze the trends of development and equity of health institutions in China during the period from 2002 to 2013 , and put forward references to optimize the decision-making on health resources alloca-tion. Methods:Statistical map, Gini coefficient and other methods were used to analyze the distribution and equity of health institutions in China for 12 years, during the period from 2002 to 2013. Results:(1) The overall development of health institutions is on the rise in China, and the distribution density of health resources with the population ad-justment is opposite to the adjustment of both population and geographic area at the same time. (2) In the past 12 years, the number of tertiary hospitals showed an increasing trend, and growth in the eastern region was the most sig-nificant. (3) From 2002 to 2013, the Gini coefficient of the number of health institutions and beds per 1,000 per-sons per square kilometer was maintained at 0. 40, and decreased from 0. 70 to 0. 60 in the eastern region of China, respectively. This same number was maintained at 0. 40 and 0. 20 in the central and western region. Conclusion: In China, the fairness trend of health resources allocation has improved during the period from 2002 to 2013, but the imbalance is more serious in the eastern region than in the central and western regions. It should be paid more atten-tion to optimizing the health resources allocation according to the local conditions of different regions, especially the influence of geographical distribution.

Competition as policy tool for public hospital reform in China / 中国卫生政策研究

The essence of the market-oriented reforms is to promote competition rather than privatization. Competition does not only exist between public and private ownership forms, but also among public hospital them-selves. The promotion of the internal competition among public hospitals will play a positive role for the market mechanism to take effect. Due to the unique in various aspects of health care market, competition can have positive or negative influences on performance, thus the policy makers need to guide the competition policies carefully to make sure they work in the right direction. In regard to the status quo, we provide the following policy suggestions which emphasize on stronger regulation, higher degree of autonomy for lower-level medical institutions, and more information disclosure.