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1.
Lancet ; 394(10204): 1192-1204, 2019 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-31571602

RESUMO

In 2009, China launched a major health-care reform and pledged to provide all citizens with equal access to basic health care with reasonable quality and financial risk protection. The government has since quadrupled its funding for health. The reform's first phase (2009-11) emphasised expanding social health insurance coverage for all and strengthening infrastructure. The second phase (2012 onwards) prioritised reforming its health-care delivery system through: (1) systemic reform of public hospitals by removing mark-up for drug sales, adjusting fee schedules, and reforming provider payment and governance structures; and (2) overhaul of its hospital-centric and treatment-based delivery system. In the past 10 years, China has made substantial progress in improving equal access to care and enhancing financial protection, especially for people of a lower socioeconomic status. However, gaps remain in quality of care, control of non-communicable diseases (NCDs), efficiency in delivery, control of health expenditures, and public satisfaction. To meet the needs of China's ageing population that is facing an increased NCD burden, we recommend leveraging strategic purchasing, information technology, and local pilots to build a primary health-care (PHC)-based integrated delivery system by aligning the incentives and governance of hospitals and PHC systems, improving the quality of PHC providers, and educating the public on the value of prevention and health maintenance.


Assuntos
Assistência à Saúde , Reforma dos Serviços de Saúde , Acesso aos Serviços de Saúde , Doenças não Transmissíveis/prevenção & controle , Atenção Primária à Saúde , Cobertura Universal do Seguro de Saúde , China , Educação em Saúde , Gastos em Saúde , Política de Saúde , Humanos , Doenças não Transmissíveis/terapia
2.
BMJ Qual Saf ; 28(12): 963-970, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31110140

RESUMO

OBJECTIVE: To empirically assess the quality of hospital care in China and trends over a 5-year period during which the government significantly increased its investment in healthcare. DESIGN: Retrospective, observational study comparing hospital quality between two periods: October 2012-March 2013 and October 2017-March 2018. SETTING: 1-2 of the most reputable large tertiary hospitals in each of the 25 provinces in Mainland China (total of 33). PARTICIPANTS: Adults 18 years or older admitted with acute myocardial infarction (AMI) (n = 7031), cerebral ischaemic stroke (n = 12 008), chronic obstructive pulmonary disease (COPD) (n = 11 836) and bacterial pneumonia (n = 4263). MAIN OUTCOME MEASURES: Process-based quality measures, including seven AMI measures, three stroke measures, four COPD measures and six pneumonia measures. RESULTS: In 2012/2013, Chinese hospitals had variable performance on AMI measures, including prescribing aspirin on arrival (80.7%), and discharging patients on aspirin (79.2%), ß-blockers (60.8%) or statins (75.8%). This was similar for stroke cases and pneumonia cases. Smoking cessation advice was given at high rates across conditions though rates of influenza/pneumococcal vaccines were performed <1%. In 2017/2018, Chinese hospitals experienced no differences across most quality measures. Performance declined for two measures: aspirin on arrival for AMI cases and blood cultures before antibiotics for pneumonia cases. Performance increased for two measures: percutaneous coronary intervention within 90 min in ST segment elevation myocardial infarction cases (66.6% vs 80.1%, p<0.001) and statins at discharge for stroke cases (64.7% vs 78.7%, p<0.001). Compared with US hospitals, Chinese hospitals underperformed across most measures. CONCLUSIONS: Chinese hospitals had low and variable performances across most quality measures for common medical conditions. Quality of care generally does not appear to be improving post national health reform. The Chinese government should include quality of care improvement in its health reform priorities to ensure patients receive appropriate and effective care.

3.
Lancet Psychiatry ; 6(4): 350-356, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30704963

RESUMO

The large and increasing burden of mental and substance use disorders, its association with social disadvantage and decreased economic output, and the substantial treatment gaps across country-income levels, are propelling mental health into the global spotlight. The inclusion of targets related to mental health and wellbeing in the UN's Sustainable Development Goals, as well as several national and global initiatives that formed during the past 5 years, signal an increasing momentum toward providing appropriate financing for global mental health. Drawing on the organisational and financial architecture of two successful global health scale-up efforts (the fight against HIV/AIDS and the improvement of maternal and child health) and the organisational models that have emerged to finance these and other global health initiatives, we propose a multi-sectoral and multi-organisational Partnership for Global Mental Health to serve two main functions. First is the mobilisation of funds, including raising, pooling, disbursing, and allocating. Second is stewardship, including supporting countries to use funds effectively, evaluate results, and hold stakeholders accountable. Such a partnership would necessarily involve stakeholders from the mental health field, civil society, donors, development agencies, and country-level stakeholders, organised into hubs responsible for financing, scale-up, and accountability.


Assuntos
Saúde Global , Saúde Mental , Saúde Global/economia , Governo , Humanos , Agências Internacionais/economia , Saúde Mental/economia , Parcerias Público-Privadas/economia , Participação dos Interessados
4.
BMC Health Serv Res ; 19(1): 43, 2019 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-30658628

RESUMO

BACKGROUND: Quality of care (QoC) attracts global concerns when unsafe and misuse of healthcare wastes resources and endangers people's health, especially in low- and middle-income countries. However, little is known about quality of care delivered in China. This study was intended to gauge the quality of care for acute myocardial infarction (AMI) patients in Beijing and identify the quality gaps across tertiary hospitals. METHODS: One thousand two hundred twenty eight patients, covered by Employee Essential Health Insurance Scheme and diagnosed of AMI, was sampled from 14 large comprehensive hospitals in Beijing, China. Chart review study was conducted through the discharge data and medical records of inpatients to evaluate 6 quality outcomes of interest, including the use of aspirin, beta blocker, and statin at discharge; use of aspirin within 24 h at arrival; angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD); percutaneous transluminal coronary intervention (PCI) within 90 min at arrival. RESULTS: Of the 1228 subjects, the mean age was 60.8 (11.8 SD) years and 83.0% were male. The overall medication prescribed was highly compliant with the clinical guidelines (97.0% [95% CI 96.8-97.2] for aspirin and 96.3% [95% CI 96.0-96.5] for statin), except for beta-blocker (83.6% [95% CI 83.0-84.1]) and ACEI/ARB use (61.4% [95% CI 60.7-62.2]). More than half of eligible patients did not receive appropriate PCI therapy (44.0% [95% CI 42.5-45.4]). Great variations across hospitals was observed in aspirin within 24 h and beta-blocker at discharge (P < 0.001), and the risk-adjusted results remained robust. CONCLUSION: Underuse of recommended treatment and significant variations of quality were found for AMI patients across tertiary hospitals in Beijing. It raised great concerns on poorer quality of care in other less-developed areas with less medical resources. Practical actions are needed in reducing quality gaps to ensure the delivery of quality care.


Assuntos
Infarto do Miocárdio/tratamento farmacológico , Qualidade da Assistência à Saúde , Centros de Atenção Terciária , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Aspirina/uso terapêutico , China , Estudos Transversais , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico
5.
Soc Sci Med ; 233: 272-280, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29548564

RESUMO

As nations strive to achieve and sustain universal health coverage (UHC), they seek answers as to what health system structures are more effective in managing health expenditure inflation. A fundamental macro-level choice a nation has to make is whether to adopt a single- or a multiple-payer health system. Using Taiwan's National Health Insurance (NHI) as a case, this paper examines how a single-payer system manages its health expenditure growth and draws lessons for other countries whose socioeconomic development is similar to Taiwan's. Our analyses show that as a single payer, Taiwan's NHI is able to exercise its monopsony power to manage its health expenditure growth. This is achieved primarily through the adoption of a system-wide global budget. The global budget sets a hard aggregate budget cap to limit NHI's total spending to its expected revenue, with the annual budget growth rate established by a process of negotiation among key stakeholders. The global budget system is complemented by comprehensive and continuous monitoring and review of encounter records of all providers and patients, enabled by the NHI's advanced information technology. However, by paying its providers using a point-based fee schedule, Taiwan's NHI suffers from inefficient service provision. In particular, providers have incentives to increase use of services and drugs with positive profit margins. Furthermore, Taiwan demonstrates that its control of NHI expenditure growth might be leading it to inadequately meet the changing needs of the population, resulting in the rapid growth of private insurance to cover services excluded or not fully covered by the NHI. If this trend persists and results in a two-tier system, Taiwan's NHI may risk compromising the equity it has achieved in the past two decades.

6.
Soc Sci Med ; 233: 265-271, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29054594

RESUMO

The United Nations has incorporated the noble goal of Universal Health Coverage (UHC) in its 2030 Agenda for Sustainable Development. Most nations have already embraced UHC as their goal. However, an intense policy debate has risen about which health system structure can best achieve UHC. Is a single-payer system more efficient, equitable and effective than a multiple-payer system for middle income countries? We argue that empirical evidence and in-depth analysis of single-payer and multiple-payer systems should inform this debate. First, we need a clear definition of single- and multiple-payer health systems that enables us to compare their differences and clarify the issues to be debated. Second, at least four key issues confront any nation that wishes to achieve UHC: (1) how to design an affordable comprehensive health benefit package for UHC and to finance it (2) how the health expenditure inflation rate can be managed to sustain UHC (3) how modern information technology can be used to enhance efficiency and quality of healthcare and (4) how to assure an adequate supply of high-quality services will be distributed equitably throughout a nation. This paper offers a definition of single- and multiple-payer and compares them. We then use Taiwan's National Health Insurance system to address the four key issues, and illuminate how its policies and operations led to Taiwan's successful UHC.

7.
Soc Sci Med ; 211: 114-122, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29935401

RESUMO

In 2012, the Chinese government launched a nationwide reform of county-level public hospitals with the goal of controlling the rapid growth of healthcare expenditure. The key components of the reform were the zero markup drug policy (ZMDP), which removed the previously allowed 15% markup for drug sales at public hospitals, and associated increases in fees for medical services. By exploiting the temporal and cross-sectional variations in the policy implementation and using a unique, nationally representative hospital-level dataset in 1880 counties between 2009 and 2014, we find that the policy change led to a reduction in drug expenditures, a rise in expenditures for medical services, and no measurable changes in total health expenditures. However, we also find an increase in expenditures for diagnostic tests/medical consumables at hospitals that had a greater reliance on drug revenues before the reform, which is unintended by policymakers. Further analysis shows that these results were more likely to be driven by the supply side, suggesting that hospitals offset the reductions in drug revenues by increasing the provision of services and products with higher price-cost margins. These findings hold lessons for cost containment policies in both developed and developing countries.


Assuntos
Custos e Análise de Custo/normas , Assistência à Saúde/economia , Medicamentos sob Prescrição/economia , China , Custos e Análise de Custo/métodos , Estudos Transversais , Assistência à Saúde/métodos , Gastos em Saúde/tendências , Política de Saúde/economia , Humanos
9.
J Contemp Brachytherapy ; 9(5): 446-452, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29204165

RESUMO

Purpose: Computed tomography (CT) is inferior to magnetic resonance imaging (MRI) in cervical tumor delineation, but similar in identification of organs at risk (OAR). The trend to over-estimate high-risk and low-risk clinical target volume (HRCTV, IRCTV) on CT can lead to under-estimation of dose received by 90% (D90) of the 'actual' CTV. This study aims to evaluate whether CT-guided planning delivers adequate dose to the 'actual' targets while spares the OAR similarly. Material and methods: MRI-guided high-dose-rate image-guided brachytherapy (IGBT) was performed in 11 patients. The pre-brachytherapy CTs were retrospectively contoured to generate CT-guided plans. MRI-based contours (HRCTVmri, IRCTVmri, bladdermri, rectummri, and sigmoidmri) were fused to CT plans for dosimetric comparison with MRI-guided plans. Paired 2-tailed t-test and Wilcoxon signed-rank test were used to analyze data. Results: 63.6% of CT plans achieved the HRCTVmriD90 constraint (≥ 7.2 Gy in one fraction), compared with 90.9% for MRI plans. > 90% of both modalities achieved the OAR's constraints (EMBRACE). The percentage of CT and MRI plans that achieved the aims (EMBRACE II) for bladder, rectum, and sigmoid were 36.4% vs. 81.8%, 63.6% vs. 63.6%, and 72.7% vs. 72.7%, respectively. There were no statistically significant differences in HRCTVmriD90, IRCTVmriD90, or dose received by the most exposed 2 cm3 (D2cc) of OARmri between the modalities. Excluding the CT plans not achieving HRCTVmriD90 constraint, there were significant increase in bladdermriD2cc, rectummriD2cc, and sigmoidmriD2cc, compared with MRI plans (0.9 Gy/Fr, 95% CI 0.2-1.5, p = 0.018; 0.9 Gy/Fr, 95% CI 0.3-1.4, p = 0.009; 0.5 Gy/Fr, 95% CI 0.2-0.9, p = 0.027, respectively). Conclusions: MRI-based IGBT remains the gold standard. CT planning may compromise HRCTVmriD90 or increase OARmriD2cc, which could decrease local control or increase treatment toxicity.

10.
Lancet ; 390(10112): 2584-2594, 2017 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-29231837

RESUMO

China has made remarkable progress in strengthening its primary health-care system. Nevertheless, the system still faces challenges in structural characteristics, incentives and policies, and quality of care, all of which diminish its preparedness to care for a fifth of the world's population, which is ageing and which has a growing prevalence of chronic non-communicable disease. These challenges include inadequate education and qualifications of its workforce, ageing and turnover of village doctors, fragmented health information technology systems, a paucity of digital data on everyday clinical practice, financial subsidies and incentives that do not encourage cost savings and good performance, insurance policies that hamper the efficiency of care delivery, an insufficient quality measurement and improvement system, and poor performance in the control of risk factors (such as hypertension and diabetes). As China deepens its health-care reform, it has the opportunity to build an integrated, cooperative primary health-care system, generating knowledge from practice that can support improvements, and bolstered by evidence-based performance indicators and incentives.


Assuntos
Atenção Primária à Saúde/organização & administração , China , Financiamento da Assistência à Saúde , Humanos , Seguro Saúde/organização & administração , Informática Médica/organização & administração , Atenção Primária à Saúde/economia , Qualidade da Assistência à Saúde , Recursos Humanos
11.
BMJ Open ; 7(8): e016195, 2017 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-28851781

RESUMO

INTRODUCTION: China has pioneered advances in primary health care (PHC) and public health for a large and diverse population. To date, the current state of PHC in China has not been subjected to systematic assessments. Understanding variations in primary care services could generate opportunities for improving the structure and function of PHC. METHODS AND ANALYSIS: This paper describes a nationwide PHC study (PEACE MPP Primary Health Care Survey) conducted across 31 provinces in China. The study leverages an ongoing research project, the China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) Million Persons Project (MPP). It employs an observational design with document acquisition and abstraction and in-person interviews. The study will collect data and original documents on the structure and financing of PHC institutions and the adequacy of the essential medicines programme; the education, training and retention of the PHC workforce; the quality of care; and patient satisfaction with care. The study will provide a comprehensive assessment of current PHC services and help determine gaps in access and quality of care. All study instruments and documents will be deposited in the Document Bank as an open-access source for other researchers. ETHICS AND DISSEMINATION: The central ethics committee at the China National Centre for Cardiovascular Disease (NCCD) approved the study. Written informed consent has been obtained from all patients. Findings will be disseminated in future peer reviewed papers, and will inform strategies aimed at improving the PHC in China. TRIAL REGISTRATION NUMBER: NCT02953926.


Assuntos
Atenção Primária à Saúde/normas , Qualidade da Assistência à Saúde , Adulto , Idoso , China , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Projetos de Pesquisa
12.
Soc Sci Med ; 181: 83-92, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28376358

RESUMO

India launched the 'Rashtriya Swasthya Bima Yojana' (RSBY) health insurance scheme for the poor in 2008. Utilising 3 waves (1999-2000, 2004-05 and 2011-12) of household level data from nationally representative surveys of the National Sample Survey Organisation (NSSO) (N = 346,615) and district level RSBY administrative data on enrolment, we estimated causal effects of RSBY on out-of-pocket expenditure. Using 'difference-in-differences' methods on households in matched districts we find that RSBY did not affect the likelihood of inpatient out-of-pocket spending, the level of inpatient out of pocket spending or catastrophic inpatient spending. We also do not find any statistically significant effect of RSBY on the level of outpatient out-of-pocket expenditure and the probability of incurring outpatient expenditure. In contrast, the likelihood of incurring any out of pocket spending (inpatient and outpatient) rose by 30% due to RSBY and was statistically significant. Although out of pocket spending levels did not change, RSBY raised household non-medical spending by 5%. Overall, the results suggest that RSBY has been ineffective in reducing the burden of out-of-pocket spending on poor households.


Assuntos
Acesso aos Serviços de Saúde/economia , Seguro Saúde/economia , Características da Família , Gastos em Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Renda/estatística & dados numéricos , Índia
13.
Health Econ ; 26(10): 1177-1190, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-27524208

RESUMO

The agency problem between patients and doctors has long been emphasised in the health economics literature, but the empirical evidence on whether patients can evaluate and respond to better quality care remains mixed and inconclusive. Using household data linked to an assessment of village doctors' clinical competence in rural China, we show that there is no correlation between doctor competence and patients' healthcare utilisation, with confidence intervals reasonably tight around zero. Household perceptions of quality are an important determinant of care-seeking behaviour, yet patients appear unable to recognise more competent doctors - there is no relationship between doctor competence and perceptions of quality. Copyright © 2016 John Wiley & Sons, Ltd.


Assuntos
Competência Clínica , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Médicos/normas , Qualidade da Assistência à Saúde , Serviços de Saúde Rural/estatística & dados numéricos , Adulto , China , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Percepção , Relações Médico-Paciente , Pobreza , Pesquisa Qualitativa
14.
Health Econ ; 25(6): 706-22, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26940721

RESUMO

In this prospective study, conducted in China where providers have traditionally been paid fee-for-service, and where drug spending is high and irrational drug prescribing common, township health centers in two counties were assigned to two groups: in one fee-for-service was replaced by a capitated global budget (CGB); in the other by a mix of CGB and pay-for-performance. In the latter, 20% of the CGB was withheld each quarter, with the amount returned depending on points deducted for failure to meet performance targets. Outcomes studied included indicators of rational drug prescribing and prescription cost. Impacts were assessed using differences-in-differences, because political interference led to non-random assignment across the two groups. The combination of capitated global budget and pay-for-performance reduced irrational prescribing substantially relative to capitated global budget but only in the county that started above the penalty targets. Endline rates were still appreciable, however, and no effects were found in either county on out-of-pocket spending. Copyright © 2016 John Wiley & Sons, Ltd.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Gastos em Saúde , Padrões de Prática Médica/estatística & dados numéricos , Reembolso de Incentivo/estatística & dados numéricos , Serviços de Saúde Rural , China , Planos de Pagamento por Serviço Prestado/economia , Pesquisas sobre Serviços de Saúde , Humanos , Estudos Prospectivos , Reembolso de Incentivo/economia
15.
Health Syst Reform ; 2(3): 213-221, 2016 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-31514596

RESUMO

In 2016, the Flagship Program for improving health systems performance and equity, a partnership for leadership development between the World Bank and the Harvard T.H. Chan School of Public Health and other institutions, celebrates 20 years of achievement. Set up at a time when development assistance for health was growing exponentially, the Flagship Program sought to bring systems thinking to efforts at health sector strengthening and reform. Capacity-building and knowledge transfer mechanisms are relatively easy to begin but hard to sustain, yet the Flagship Program has continued for two decades and remains highly demanded by national governments and development partners. In this article, we describe the process used and the principles employed to create the Flagship Program and highlight some lessons from its two decades of sustained success and effectiveness in leadership development for health systems improvement.

17.
Health Aff (Millwood) ; 34(10): 1745-52, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26438752

RESUMO

In 2009 China announced plans to reform provider payment methods at public hospitals by moving from fee-for-service (FFS) to prospective and aggregated payment methods that included the use of diagnosis-related groups (DRGs) to control health expenditures. In October 2011 health policy makers selected six Beijing hospitals to pioneer the first DRG payment system in China. We used hospital discharge data from the six pilot hospitals and eight other hospitals, which continued to use FFS and served as controls, from the period 2010-12 to evaluate the pilot's impact on cost containment through a difference-in-differences methods design. Our study found that DRG payment led to reductions of 6.2 percent and 10.5 percent, respectively, in health expenditures and out-of-pocket payments by patients per hospital admission. We did not find evidence of any increase in hospital readmission rates or cost shifting from cases eligible for DRG payment to ineligible cases. However, hospitals continued to use FFS payments for patients who were older and had more complications than other patients, which reduced the effectiveness of payment reform. Continuous evidence-based monitoring and evaluation linked with adequate management systems are necessary to enable China and other low- and middle-income countries to broadly implement DRGs and refine payment systems.


Assuntos
Controle de Custos/estatística & dados numéricos , Gastos em Saúde/normas , Hospitalização/estatística & dados numéricos , China , Hospitais , Humanos , Projetos Piloto
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