Determinants of basic public health services provision by village doctors in China: using non-communicable diseases management as an example.

BACKGROUND: To ensure equity and accessibility of public health care in rural areas, the Chinese central government has launched a series of policies to motivate village doctors to provide basic public health services. Using chronic disease management and prevention as an example, this study aims to identify factors associated with village doctors' basic public health services provision and to formulate targeted interventions in rural China. METHODS: Data was obtained from a survey of village doctors in three provinces in China in 2014. Using a multistage sampling process, data was collected through the self-administered questionnaire. The data was then analyzed using multilevel logistic regression models. RESULTS: The high-level basic public health services for chronic diseases (BPHS) provision rate was 85.2% among the 1149 village doctors whom were included in the analysis. Among individual level variables, more education, more training opportunities, receiving more public health care subsidy (OR = 3.856, 95 % CI: 1.937-7.678, and OR = 4.027, 95% CI: 1.722-9.420), being under integrated management (OR = 1.978, 95% CI: 1.132-3.458), and being a New Cooperative Medical Scheme insurance program-contracted provider (OR = 2.099, 95% CI: 1.187-3.712) were associated with the higher BPHS provision by village doctors. Among county level factors, Foreign Direct Investment Index showed a significant negative correlation with BPHS provision, while the government funding for BPHS showed no correlation (P > 0.100). CONCLUSION: Increasing public health care subsidies received by individual village doctors, availability and attendance of training opportunities, and integrated management and NCMS contracting of village clinics are important factors in increasing BPHS provision in rural areas.

Health care utilization in older people with cardiovascular disease in China.

BACKGROUND: Population is ageing rapidly and prevalence of cardiovascular diseases is increasing in China. This study aims to examine the patterns of outpatient and inpatient health care utilization across different demographic and socioeconomic groups in older people with cardiovascular disease in China. METHODS: Data were from World Health Organization (WHO) Study on Global Aging and Adult Health (SAGE) Wave 1. Chinese older people aged over 50 years with cardiovascular disease were included in the analysis. Outpatient and inpatient care utilization rates were presented and compared by demographic and socioeconomic characteristics. Multivariable logistic regression was used to examine the association between socioeconomic factors and health care utilization. RESULTS: In total, 4162 older people with cardiovascular disease in SAGE China Wave 1 were included in the analysis. 86.4% of them had health insurance. 54.9% of the patients received outpatient care and 17.7% received inpatient care over the past 12 months. Outpatient care utilization rate was significantly associated with age. Patients in older groups used more outpatient care than those in younger groups (p = 0.010). Inpatient care utilization rate peaked at 70-79 years group (23.2%), and then reduced to 17.5% in 80 years plus group. Rich patients used more outpatient service than the poorer (p < 0.001). No association was found between household wealth status and inpatient service utilization. CONCLUSION: Within the context of high health insurance coverage in China, the pattern of outpatient care utilization differs from that of inpatient care utilization among older patients aged over 50 years old with cardiovascular disease. Patients tend to use more outpatient care as they became older. As for inpatient care, the oldest patients aged over 80 years use less inpatient care than the 70-79 group. Household economic status plays an important role in outpatient care utilization, but it shows no association with inpatient care utilization in Chinese older patients.

Modifiable exposures to air pollutants related to asthma phenotypes in the first year of life in children of the EDEN mother-child cohort study.

BACKGROUND: Studies have shown diverse strength of evidence for the associations between air pollutants and childhood asthma, but these associations have scarcely been documented in the early life. The purpose of this study was to evaluate the impacts of various air pollutants on the development of asthma phenotypes in the first year of life. METHODS: Adjusted odds ratios were estimated to assess the relationships between exposures to air pollutants and single and multi-dimensional asthma phenotypes in the first year of life in children of the EDEN mother-child cohort study (n = 1,765 mother-child pairs). The Generalized Estimating Equation (GEE) model was used to determine the associations between prenatal maternal smoking and in utero exposure to traffic-related air pollution and asthma phenotypes (data were collected when children were at birth, and at 4, 8 and 12 months of age). Adjusted Population Attributable Risk (aPAR) was estimated to measure the impacts of air pollutants on health outcomes. RESULTS: In the first year of life, both single and multi-dimensional asthma phenotypes were positively related to heavy parental smoking, traffic-related air pollution and dampness, but negatively associated with contact with cats and domestic wood heating. Adjusted odds ratios (aORs) for traffic-related air pollution were the highest [1.71 (95% Confidence Interval (CI): 1.08-2.72) for ever doctor-diagnosed asthma, 1.44 (95% CI: 1.05-1.99) for bronchiolitis with wheezing, 2.01 (95% CI: 1.23-3.30) for doctor-diagnosed asthma with a history of bronchiolitis]. The aPARs based on these aORs were 13.52%, 9.39%, and 17.78%, respectively. Results persisted for prenatal maternal smoking and in utero exposure to traffic-related air pollution, although statistically significant associations were observed only with the asthma phenotype of ever bronchiolitis. CONCLUSIONS: After adjusting for potential confounders, traffic-related air pollution in utero life and in the first year of life, had a greater impact on the development of asthma phenotypes compared to other factors.

Impact of financial and educational interventions on maternity care: results of cluster randomized trials in rural China, CHIMACA.

To report on the design and basic outcomes of three interventions aimed at improving the use and quality of maternity care in rural China: financial interventions, training in clinical skills, and training in health education. Community-based cluster randomized trials were carried out in one central and two western provinces between 2007 and 2009: (1) financial interventions covered part of women's costs for prenatal and postnatal care, (2) training of midwives in clinical skills was given by local maternity care experts in two- or three-group training courses, (3) health education training for midwives and village doctors were given by local experts in health education in two- or three-group training courses. A survey was conducted in a stratified random sample of women who had been pregnant in the study period. 73% of women (n = 3,673) were interviewed within 1-10 months of giving birth. Outcomes were compared by the different intervention and control groups. Adjusted odds ratios were calculated by logistic regression to adjust for varying maternal characteristics. Most of the differences found between the groups were small and some varied between provinces. The financial intervention did not influence the number of visits, but was associated with increased caesarean sections and a decrease in many ultrasound tests. The clinical intervention influenced some indicators of care content. There was no consistent finding for the health education intervention. Financial and training interventions have the potential to improve maternity care, but better implementation is required. Unintended consequences, including overuse of technology, are possible.

[Analysis of the difference in free influenza vaccination rates between old people in urban and rural areas in Beijing].

OBJECTIVE: To assess the status of free influenza vaccination rates for the elderly in Beijing. METHODS: A questionnaire survey was carried out among 1 000 old people in Beijing. Random sampling method was employed. Descriptive analysis and Chi square test were used for statistical analysis, and Logistic regression model was used to analyze the difference in free influenza vaccination rates between the urban and rural areas. RESULTS: The continuous influenza vaccination rate of the elderly from 2007 to 2010 was 46.4%, which was higher in the rural (70.9%) than in the urban (38.3%). The vaccination rate in the rural was 3.859 times that in the urban, after other variables were controlled. CONCLUSION: The vaccination rate among the elderly in Beijing has been raised after the implementation of free influenza vaccination policy in 2007, especially for the rural people. In the urban areas, concerning about the safety of the vaccine is one of the reasons why people chose not to take free influenza vaccination; while in the rural, the insufficient knowledge about the flu and influenza vaccine plays an important role.

Building quality primary health care development in the new era towards universal health coverage: a Beijing initiative.

Primary health care (PHC) is the most effective way to improve people's health and well-being, and primary care services should act as the cornerstone of a resilient health system and the foundation of universal health coverage. To promote high quality development of PHC, an International Symposium on Quality Primary Health Care Development was held on December 4-5, 2023 in Beijing, China, and the participants have proposed and advocated the Beijing Initiative on Quality Primary Health Care Development. The Beijing Initiative calls on all countries to carry out and strengthen 11 actions: fulfill political commitment and accountability; achieve "health in all policies" through multisectoral coordination; establish sustainable financing; empower communities and individuals; provide community-based integrated care; promote the connection and integration of health services and social services through good governance; enhance training, allocation and motivation of health workforce, and medical education; expand application of traditional and alternative medicine for disease prevention and illness healing; empower PHC with digital technology; ensure access to medicinal products and appropriate technologies; and last, strengthen global partnership and international health cooperation. The Initiative will enrich the content of quality development of PHC, build consensus, and put forward policies for quality development of PHC in China in the new era, which are expected to make contributions in accelerating global actions.

[Relation between social capital factors and self-rated health among Chinese adults].

OBJECTIVE: To examine the relations between factors of social capital and self-rated health among Chinese adults. METHODS: Univariate and multivariate analyses were used, based on 33 610 respondents in cross-sectional data of Chinese Family Panel Studies implemented by Institute of Social Science Survey, Peking University. RESULTS: In the study, 47.4% of the respondents reported "good" in self-rated health. The result of univariate analysis showed that those who took part in any organizations (P<0.001) or had frequent interaction with others (P<0.001) tended to report relatively higher level on self-rated health. After controlling the physical health and demographic factors, the social participation (P<0.01), social interaction (P<0.001) and perceived social equity (P<0.001) were all the correlates of self-rated health among Chinese residents. CONCLUSION: Factors of social capital are important correlates of self-rated health in China, controlling the physical health and demographic factors. self-rated health can indicate people's social health to certain extent.

Patient medical costs for tuberculosis treatment and impact on adherence in China: a systematic review.

BACKGROUND: Charging for tuberculosis (TB) treatment could reduce completion rates, particularly in the poor. We identified and synthesised studies that measure costs of TB treatment, estimates of adherence and the potential impact of charging on treatment completion in China. METHODS: Inclusion criteria were primary research studies, including surveys and studies using qualitative methods, conducted in mainland China. We searched MEDLINE, PUBMED, EMBASE, Science Direct, HEED, CNKI to June 2010; and web pages of relevant Chinese and international organisations. Cost estimates were extracted, transformed, and expressed in absolute values and as a percentage of household income. RESULTS: Low income patients, defined at household or district level, pay a total of US$ 149 to 724 (RMB 1241 to 5228) for medical costs for a treatment course; as a percentage of annual household income, estimates range from 42% to 119%. One national survey showed 73% of TB patients at the time of the survey had interrupted or suspended treatment, and estimates from 9 smaller more recent studies showed that the proportion of patients at the time of the survey who had run out of drugs or were not taking them ranged from 3 to 25%. Synthesis of surveys and qualitative research indicate that cost is the most cited reason for default. CONCLUSIONS: Despite a policy of free drug treatment for TB in China, health services charge all income groups, and costs are high. Adherence measured in cross sectional surveys is often low, and the cumulative failure to adhere is likely to be much higher. These findings may be relevant to those concerned with the development and spread of multi-drug resistant TB. New strategies need to take this into account and ensure patient adherence.

The Happy Life Club™ study protocol: a cluster randomised controlled trial of a type 2 diabetes health coach intervention.

BACKGROUND: The Happy Life Club™ is an intervention that utilises health coaches trained in behavioural change and motivational interviewing techniques to assist with the management of type 2 diabetes mellitus (T2DM) in primary care settings in China. Health coaches will support participants to improve modifiable risk factors and adhere to effective self-management treatments associated with T2DM. METHODS/DESIGN: A cluster randomised controlled trial involving 22 Community Health Centres (CHCs) in Fengtai District of Beijing, China. CHCs will be randomised into a control or intervention group, facilitating recruitment of at least 1320 individual participants with T2DM into the study. Participants in the intervention group will receive a combination of both telephone and face-to-face health coaching over 18 months, in addition to usual care received by the control group. Health coaching will be performed by CHC doctors and nurses certified in coach-assisted chronic disease management. Outcomes will be assessed at baseline and again at 6, 12 and 18 months by means of a clinical health check and self-administered questionnaire. The primary outcome measure is HbA1c level. Secondary outcomes include metabolic, physiological and psychological variables. DISCUSSION: This cluster RCT has been developed to suit the Chinese health care system and will contribute to the evidence base for the management of patients with T2DM. With a strong focus on self-management and health coach support, the study has the potential to be adapted to other chronic diseases, as well as other regions of China. TRIAL REGISTRATION: Current Controlled Trials ISRCTN01010526.

[Comparative analysis of applying patient experience and satisfaction survey (VPSM) tool in Chinese hospitals].

OBJECTIVE: Patient experience and satisfaction survey has been regarded as an important method of collecting patients' opinions on medical services and improving the quality of management. From 2005 to 2009, Australia Victorian patient satisfaction monitoring, VPSM, was introduced, localized and adopted by over 50 Chinese hospitals. To compare and analyze each localized applications of VPSM and submit suggestions for further applications. METHODS: The paper adopted the way of document research. The researchers collected all of the published and unpublished investigation plans and monitoring reports during these five years, compared the operations and the results of investigations and indicated the advantages and weaknesses. RESULTS: In respect of methods, they were similar but showed some small differences in details such as the questionnaire structure, the reminding letter and the organization of data acquisition and analysis. The localized VPSM was gradually moving towards standardization. The monitoring was able to find the changing of medical services and provided the referential information for management. CONCLUSION: The localization of VPSM is still on its way and it needs improving by means of extending application.

Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co-operative Medical System).

SUMMARY OBJECTIVE: To investigate factors influencing maternal health care utilisation in western rural China and its relation to income before (2002) and after (2007) introducing a new rural health insurance system (NCMS). METHODS: Data from cross-sectional household-based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log-linear model. RESULTS: Between 2002 and 2007, having no any pre-natal visit decreased from 25% to 12% (difference 13%, 95% CI 10-17%); facility-based delivery increased from 45% to 80% (difference 35%, 95% CI 29-37%); and differences in using pre-natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre-natal and delivery care in 2007. The expenditure for facility-based delivery increased over the period, but the out-of-pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low-income group. NCMS participation was found positively correlated with lower out-of-pocket expenditure for facility-based delivery (coefficient -1.14 P < 0.05) in 2007. CONCLUSIONS: Facility-based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility-based delivery, although NCMS participation reduced the out-of-pocket expenditure on average.

Utilisation, contents and costs of prenatal care under a rural health insurance (New Co-operative Medical System) in rural China: lessons from implementation.

BACKGROUND: In China, the New Co-operative Medical System (NCMS), a rural health insurance system, has expanded nationwide since 2003. This study aims to describe prenatal care use, content and costs of care in one county where prenatal care is included in the NCMS and two counties where it is not. It also explores the perceptions of stakeholders of the prenatal care benefit package in order to understand the strengths and weaknesses of the approach in the context of rural China and to draw lessons from early implementation. METHODS: This study is based on the data from a cross-sectional survey and a qualitative investigation conducted in 2009. A survey recruited women giving birth in 2008, including 544 women in RC County (which covered prenatal care) and 619, and 1071 in other two counties (which did not). The qualitative investigation in RC included focus group discussions with women giving birth before or after 2007, individual interviews with local policy makers and health managers, NCMS managers and obstetric doctors in township hospitals. RESULTS: There were no significant differences in prenatal care use between RC County (which covered prenatal care) and other two counties (which did not): over 70% of women started prenatal visits early and over 60% had five or more visits. In the three counties: a small proportion of women received the number of haemoglobin and urine tests recommended by the national guideline; 90% of women received more ultrasound tests than recommended; and the out-of-pocket expenditure for prenatal care consumed a high proportion of women's annual income in the low income group. In RC: only 20% of NCMS members claimed the reimbursement; the qualitative study found that the reimbursement for prenatal care was not well understood by women and had little influence on women's decisions to make prenatal visits; and several women indicated that doctors suggested them taking more expensive tests. CONCLUSIONS: Whether or not prenatal care was included in the NCMS, prenatal care use was high, but the contents of care were not provided following the national guideline and more expensive tests were recommended by doctors. Costs were substantial for the poor.

[Determinants of self-rated health in old people].

OBJECTIVE: To describe the status of self-rated health (SRH) among the elderly and find out the relationship between SRH and other health measures such as two weeks prevalence and chronic disease prevalence. METHODS: The data used was generated from cross-sectional household health survey conducted in the year of 2009 in Shunyi district, Beijing. SPSS software was used to conduct univariate and multivariate liner regression analysis with self-rated health. RESULTS: The average score of self-rated health among the elderly is 72.49. Univariate analyses suggest that are age, sex, marital status, income level, education, employment, medical insurance type, self-perceived anxious or depression, disease state are all associated with poor SRH score. Multiple liner regression model shows that age, job, medical insurance, self-perceived anxious or depression, suffer from two-week illness and chronic disease had effects on SRH of the elderly. CONCLUSION: Physical and psychological unhealthy are independent risk factors of SRH among the elderly, disease status is the most influential predictor on SRH score. Thus, a single measurement of SRH question can be used in health status assessment of the elderly.

Association between early essential newborn care and breastfeeding outcomes in eight countries in Asia and the Pacific: a cross-sectional observational -study.

OBJECTIVE: To explore the association between early essential newborn care (EENC) policy, practice and environmental interventions and breastfeeding outcomes. DESIGN: Cross-sectional observational study. SETTING: 150 national, provincial and district hospitals implementing EENC in eight countries in East Asia and the Pacific. PARTICIPANTS: 1383 maternal interviews, chart reviews and environmental assessments during 2016 and 2017. MAIN OUTCOME MEASURES: Exclusive breastfeeding (EBF), that is, feeding only breastmilk without other food or fluids since birth and before discharge, and, early breastfeeding initiation, that is, during skin-to-skin contact (SSC) with the mother without separation. RESULTS: Fifty-nine per cent of newborns initiated breastfeeding early and 83.5% were EBF. Duration of SSC showed a strong dose-response relationship with early breastfeeding initiation. SSC of at least 90 min was associated with 368.81 (95% CI 88.76 to 1532.38, p<0.001) times higher early breastfeeding. EBF was significantly associated with SSC duration of 30-59 min (OR 3.54, 95% CI 1.88 to 6.66, p<0.001), 60-89 min (OR 5.61, 95% CI 2.51 to 12.58, p<0.001) and at least 90 min (OR 3.78, 95% CI 2.12 to 6.74, p<0.001) regardless of delivery mode. Non-supine position (OR 2.80, 95% CI 1.90 to 4.11, p<0.001), rooming-in (OR 5.85, 95% CI 3.46 to 9.88, p<0.001), hospital breastfeeding policies (OR 2.82, 95% CI 1.97 to 4.02, p<0.001), quality improvement mechanisms (OR 1.63, 95% CI 1.07 to 2.49, p=0.02) and no formula products (OR 17.50, 95% CI 5.92 to 51.74, p<0.001) were associated with EBF. CONCLUSION: EENC policy, practice and environmental interventions were associated with breastfeeding outcomes. To maximise the likelihood of early and EBF, newborns, regardless of delivery mode, should receive immediate and uninterrupted SSC for at least 90 min.

[Influence of patients' attitude on doctors' satisfaction with the doctor-patient relationship].

OBJECTIVE: To describe the doctors' satisfaction of the doctor-patient relationship and find out the influencing factors of the patients, gathering evidence to improve the doctor-patient relationship. METHODS: This study was a cross-sectional study, in which doctors and nurses in 10 hospitals of Beijing, Shandong and Chongqing were surveyed with structured questionnaires and in-depth interviews. RESULTS: The mean score of the doctors' satisfaction of the doctor-patient relationship was 59.97, which was much lower than the patients'. The patients' socio-demographic characteristics, social economic status (SES) and behavior characteristics influence the interaction of the doctors and the patients. The doctors' satisfaction of the doctor-patient relationship was influenced by the patients' trust. CONCLUSION: The doctors' perspective is helpful to define the tension and the cause of the doctor-patient relationship. The patients' characteristics have important influence on the doctor-patient relationship. It's necessary to take action on the patients to improve the doctor-patient relationship.

Effect of a Health Coach Intervention for the Management of Individuals With Type 2 Diabetes Mellitus in China: A Pragmatic Cluster Randomized Controlled Trial.

Aim: To determine the effect of a health coach intervention for the management of glycemic control, as well as physiological, psychological and self-care outcomes of patients with type 2 diabetes mellitus (T2DM), compared with usual care. Methods: This pragmatic cluster RCT was conducted in the Fengtai district of Beijing from August 2011 to December 2013. Forty-one community health stations (CHSs) were cluster randomized (stratified geographically, 1:1 ratio) and eligible, randomly selected T2DM patients were sequentially contacted by CHSs. Control participants received usual care according to the Chinese Guideline for Diabetes Prevention and Management. Intervention participants received 18-months of health coaching based on principles of Motivational Interviewing (MI) plus usual care. Medical and pathology fees were waived for both groups. Outcome assessment was performed at baseline, 6, 12, and 18-months. The primary outcome was glycated hemoglobin (HbA1c); secondary outcomes encompassed a suite of physiological, psychological and self-care measures. Results: No differential treatment effect was found at 18-months for HbA1c (adj. difference -0.07, 95% CI -0.53 to 0.39, p = 0.769) or any specified secondary outcomes. Interestingly, both groups displayed a statistically and clinically significant within-group improvement of the same magnitude at 18-months for HbA1c (intervention: mean change -3.65, 95% CI -3.92 to -3.37; control: mean change -3.38, 95% CI -3.67 to -3.08). Conclusions: The lack of differential treatment effects observed indicate that it may be premature to recommend the routine delivery of health coach interventions based on MI principles for the management of T2DM in China. However, the large, comparable within-group improvement in mean HbA1c promotes the establishment of free, regular clinical health assessments for individuals with T2DM in China. TRIAL REGISTRATION: ISRCTN registry - ISRCTN01010526 (https://doi.org/10.1186/ISRCTN01010526).

Epidemiologic study on Kawasaki disease in Beijing from 2000 through 2004.

A hospital-based survey of Kawasaki disease was performed in all 45 hospitals with in-patient beds in Beijing during the 5-year period from 2000 through 2004. A total of 1107 patients were enrolled, with an annual incidence varying from 40.9 to 55.1 per 100,000 children <5 years of age. The incidence of coronary complications was 20.6% in the acute stage, and 6.9% in the 1-2 month follow-up.

Persistent problems of access to appropriate, affordable TB services in rural China: experiences of different socio-economic groups.

BACKGROUND: Large-scale Tuberculosis (TB) control programmes in China have been hailed a success. Concerns remain, however, about whether the programme is reaching all sections of the population, particularly poorer groups within rural communities, and whether there are hidden costs. This study takes a household perspective to investigate receipt of appropriate care and affordability of services for different socio-economic groups with TB symptoms in rural China. METHODS: Secondary analysis of Chinese National Household Health Survey for 2003: 40,000 rural households containing 143,991 individuals, 2,308 identified as TB suspects. OUTCOMES: use of services and expenditure of TB suspects, by gender and socio-economic position, indicated by household income, education, material assets, and insurance status. RESULTS: 37% of TB suspects did not seek any professional care, with low-income groups less likely to seek care than more affluent counterparts. Of those seeking care, only 35% received any of the recommended diagnostic tests. Of the 182 patients with a confirmed TB diagnosis, 104 (57%) received treatment at the recommended level, less likely if lacking health insurance or material assets. The burden of payment for services amounted to 45% of annual household income for the low-income group, 16% for the high-income group. CONCLUSION: Access to appropriate, affordable TB services is still problematic in some rural areas of China, and receipt of care and affordability declines with declining socio-economic position. These findings highlight the current shortcomings of the national TB control programme in China and the formidable challenge it faces if it is to reach all sections of the population, including the poor with the highest burden of disease.

Perceptions of tuberculosis and health seeking behaviour in rural Inner Mongolia, China.

PURPOSE: This study aimed to explore perceptions of TB, and health care seeking pathways, among poor rural communities in Inner Mongolia. METHODOLOGY: Twenty focus group discussions (FGDs) were held and 105 farmers were included. Six hundred and fourteen randomly selected respondents were surveyed through interview questionnaire, in three poor rural counties with a high TB prevalence. MAIN FINDINGS: A substantial proportion of community members were unclear or misinformed as to how TB was transmitted. Sixty percent of respondents identified prolonged cough as a main symptom of TB, while only 40% perceived TB to be caused by 'close interaction with TB patient'. In addition, 70% could not afford TB treatment and fell into debt as a result of having to seek medical care. Social stigma associated with TB influenced marriage prospects and impeded important social interactions within the community. Respondents' perceptions of TB were associated with their socio-economic status. Women, young people, low-income groups and those with less education tended to be less knowledgeable about TB. All farmers in the study reported only seeking health care after they failed to treat themselves; and most of them then sought care from less qualified village level health care providers. Less educated people, low-income groups and old people were identified as less likely to seek care, or more likely to seek care at village level where it is cheaper. Both financial and structural barriers were found to stop farmers seeking health care. CONCLUSIONS AND POLICY IMPLICATIONS: Perceptions of TB and social stigma associated with the disease, together with socio-economic factors, shape the health seeking behaviour of poor farmers. Accessibility and affordability of TB health care issues should be dealt with through a multi-pronged approach, including health promotion in addition to expansion of the DOTS strategy and rural health insurance schemes.

How close have universal health systems come to achieving equity in use of curative services? A systematic review.

Most governments in established market economies have developed universal systems of health care, but these are being increasingly threatened by widespread health sector reforms. Hence, it is more important than ever to monitor the effects of policy changes on the ability of universal systems to achieve their equity goals. This article provides evidence for such monitoring. The authors present the results of a systematic review of equity in use of curative health services in universal systems, together with a critical appraisal of the essential components of studies to address this question. Of the 79 studies identified that addressed the review question, only 26 met the inclusion criteria and adjusted for differential health need across socioeconomic groups. The authors found a pro-rich bias in use of specialist hospital services and a reasonably equitable access to primary health care by different socioeconomic groups. There was a wide inter-study variation in the difference in utilization rates between people of high and low socioeconomic groups. Improvements are needed in the way that equity in universal systems is monitored, with particular attention to how "need" is defined and to the impact on patients of indirect costs.