Health policy and planning最新文献

A hierarchical medical system anchored in primary healthcare is a critical mechanism for global healthcare systems to alleviate financing pressures and enhance health outcomes. Leveraging panel data from Zhejiang Province (2017-2022), this study evaluates how regional global budget payment reforms, implemented within county medical communities, influence the progression of the hierarchical medical system. The reforms were associated with a 3.0% (90% CI: -6.3 to 0.3, P < 0.1) reduction in patient volumes at county-level hospitals and a 30.2% (95% CI: 3.1-57.4, P < 0.05) surge in downward referrals to primary institutions. Concurrently, primary facilities saw an 8.3% (95% CI: 0.56-16.0, P < 0.05) increase in outpatient visits and 6.9% (95% CI: 0.15-13.7, P < 0.05) revenue growth. From the perspective of health performance, there was a 1.33% (95% CI: -2.57 to -0.09, P < 0.05) reduction in premature mortality from major chronic diseases. Mechanism analysis reveals that the regional global budget payment reshapes the incentives for both county-level hospitals and primary healthcare institutions. Under cost-containment pressures, county-level hospitals strategically redirect non-critical patients to primary healthcare institutions through formal referral protocols, while the latter are financially incentivized to provide healthcare services. These findings demonstrate how payment reforms can recalibrate provider behavior in vertically integrated systems, offering an explorable pathway for building people-centered, integrated healthcare systems through health insurance leverage.

A long-standing concern suggests that performance-based financing (PBF) may undermine the intrinsic motivation of health workers by heightening extrinsic motivation concerns via the novel introduction of financial incentives. However, the theoretical effect of PBF on worker motivation and job satisfaction is ambiguous as these programs may also improve working conditions, staff engagement, and other factors that determine health worker morale. We use data from six evaluations of national pilots to empirically assess the effect of PBF on worker motivation and job satisfaction. In these six pilots (in Cameroon, Kyrgyz Republic, Nigeria, Tajikistan, Zambia, and Zimbabwe), geographical units (or health facilities) were either randomized or quasi-experimentally assigned to receive PBF or the alternatives of direct facility financing (DFF), enhanced supervision (ES), or business-as-usual comparison arms. Baseline and endline health worker surveys were carried out in the context of these national pilots. The primary outcomes investigated here are health worker motivation and job satisfaction. Secondary outcomes include subconstructs of health worker motivation and job satisfaction extracted using exploratory factor analysis. For two countries out of six-Nigeria and Kyrgyz Republic-we find increases in overall worker motivation and null effects in the other four when contrasting PBF with the business-as-usual comparison. For five countries out of six (all but Cameroon), we find increases in job satisfaction. Further, PBF did not have any systematic motivating or demotivating effects when compared with the health system intervention alternatives of DFF and ES (each in a subset of countries), except in Nigeria where satisfaction in the PBF arm was lower when compared with DFF. All told, these results contain practically no evidence of an adverse effect of PBF on overall health worker motivation or job satisfaction and indeed suggest a beneficial impact in some country settings.

This study examines the substitution effects and complementary dynamics between outpatient and inpatient services across different levels of hospital care in China's tiered healthcare system. The data of this study originated from official administrative medical insurance reimbursement records from 2013 to 2019, with a final sample size of 1 520 263 patients. Using individual-level data and controlling for regional variations through fixed-effects models, we identify significant patterns in healthcare utilization that provide actionable insights for enhancing system efficiency. We have found a notable substitution effect: increased utilization of primary care services was negatively associated with the demand for secondary and tertiary care, thereby supporting ongoing health policy reforms. Additionally, outpatient services at primary care facilities could reduce the demand for both outpatient and inpatient services at higher-level hospitals. The homogeneity of outpatient services further facilitated substitution across care levels, allowing primary and secondary care to increasingly manage clinical cases previously handled by tertiary hospitals. Finally, we explored the complementary relationship between outpatient and inpatient services within the same care level, emphasizing highlighting how financial incentives contribute to induced hospitalization in China's healthcare system. These findings suggest that healthcare policies must be adjusted to address systemic inefficiencies and realign financial incentives in order to improve resource allocation and patient care.

Cambodia is experiencing a growing burden of non-communicable diseases (NCDs) as it undergoes an epidemiological transition. This qualitative study investigates the health-seeking behaviors of Cambodians in the context of hypertension and diabetes, focusing on the utilization of both formal healthcare and alternative medical practices. Data are from 20 in-depth interviews with participants without social health protection and 6 focus groups (n = 48), involving beneficiaries of the Health Equity Fund (HEF) and National Social Security Fund (NSSF). The research explores personal experiences with NCD management, perceptions of social health protection schemes, and perceived barriers to accessing healthcare. Data were collected in urban and rural settings in Cambodia, with thematic analysis facilitated by NVivo 14 software. Many participants delayed seeking biomedical advice due to economic constraints, cultural beliefs, and perceived inadequacies in the healthcare system. Traditional remedies and self-medication were commonly reported, often due to their accessibility and lower cost compared to biomedical healthcare services. Despite the availability of HEF and NSSF, structural challenges within the healthcare system, such as shortages of medications and trained staff at public health centers, emerged as significant barriers. Pharmacy workers and village healers are insufficiently utilized human resources. Formalizing their role in the secondary prevention of NCDs could contribute to the early detection of diabetes and hypertension. The findings suggest the need for an integrated health system that strengthens the capacity of primary care facilities to manage NCDs effectively and utilizes the semi-professional sector more systematically. Strengthening primary care, expanding service availability, and improving social health protection schemes are essential to reduce health disparities and improve access to quality care for NCDs in Cambodia.

Subjective well-being (SWB) is increasingly recognized as a critical indicator of healthy ageing. While prior studies highlight the importance of health behaviours, few examine how multidimensional health investments influence SWB across different levels of well-being. This paper explores the relationship between health investment and SWB among older adults in China, using data from the 2018 Chinese Longitudinal Healthy Longevity Survey. Health investment is categorized into 4 domains: nutrition, healthcare access (insurance coverage and health product use), lifestyle behaviours (including exercise, smoking, and drinking), and living environment (access to clean drinking water). Quantile regression models are applied to assess heterogeneous effects across the SWB distribution, while mediation analysis investigates the role of self-rated health and functional health (activities of daily living) as potential pathways. Results show that the positive effects of nutrition and exercise are the most pronounced among individuals with lower SWB, while smoking and drinking exhibit stronger negative associations in this group. Mediation results suggest that perceived health plays a more consistent role than functional status in translating health investment into higher well-being. The impact of insurance is observed primarily through interaction effects, magnifying benefits from healthy behaviours and buffering risks from harmful ones. These findings point to the need for equity-sensitive ageing policies that target both health behaviours and social protection. Specifically, integrating social work and behavioural counselling into primary health outreach may help address substance-related risks and psychological vulnerabilities among the elderly. This evidence has wider relevance for ageing societies, particularly in low- and middle-income countries aiming to align health system goals with subjective well-being outcomes.

Literature suggests that individuals may trade off health for income in face of an economic shock. Being in a close contact profession, the livelihoods of sex workers were severely affected by the COVID-19 pandemic. Few studies exist on whether prevalence of better-renumerated condomless sex increased among this population in low and middle-income countries and discuss its implications on HIV/STI transmission, specifically during pandemic situations. We reported cross-sectional condom use prevalence estimates of 600 female sex workers in Dakar, Senegal from data collected before (2015, 2017) and during the pandemic (June-July 2020). Condom use prevalence was elicited via list experiments for more truthful estimates. Double list experiment estimates of mean condom use prevalence declined from 78.2% (95% CI: 70.9-85.5%) in 2017 to 65.1% (95% CI: 57.6-72.7%) in 2020. This statistically significant decrease of 13.1 percentage points (P = .014) represents a 16.8% fall in condom use and a 60.2% increase in condomless sex prevalence. The fall in condom use prevalence was largely concentrated amongst the asset-poor, providing some suggestive evidence that economic reasons drove the fall in condom use, reinforcing findings in existing literature regarding the positive relationship between economic shocks and risky sexual behaviours. At the point of the survey, the observed decline in client numbers exceeded the reduction in condom use prevalence, suggesting potential mitigation of HIV/STI transmission risks during the COVID-19 pandemic; nevertheless, the lack of direct comparability between these two metrics warrants cautious interpretation. However, more accurate epidemiological modelling considering the non-sex worker population and longer-term studies on whether condom use prevalence returned to pre-COVID levels after client numbers recovered are required for a comprehensive assessment of the pandemic's short-term and longer-term impact on HIV/STI transmission.

Households with ill members often face financial hardship when seeking healthcare. Households mobilize their resources from various sources to pay for treatment costs. Financially, some households resort to borrowing money and selling their assets. This type of financial coping strategy is called distress financing (DF). This study aims to estimate the prevalence and determinants of DF among households with hospitalized members at University Malaya Medical Centre, Malaysia. It further explores the dynamics of DF and its impact on households' welfare by employing a convergent mixed-method approach. Quantitative data were collected using a structured interview. Households having reported to either borrow money, sell their assets, and/or withdraw from an employee provident fund were categorized as those suffering DF. To explore how households coped with high medical expenses and the consequences of DF, seven households adopting more than one DF strategy were purposively selected for in-depth interview. Of 199 households, 22 (11.1%) reported undergoing DF. Psychological distress, medical indebtedness, and poverty were typical consequences of DF. During hardship, the social network played a principal role in alleviating the financial burden, further emphasizing the importance of kinship. Households undergoing catastrophic health expenditure, headed by Chinese ethnicity, living in states other than Selangor, and living in a rental house were 8.2, 4.6, 4.4, and 3.5 times more likely to undergo DF, respectively. Targeted assistance in removing financial barriers would assure the continuum of care among households possibly suffering DF, thereby improving their health outcomes.

While health is a fundamental right, health inequities between urban and rural residents remain significant in China. Medical consortia aim to bridge this gap by providing equitable and affordable healthcare. However, their effectiveness in enhancing health equity remains underexplored. This study aims to explore whether medical consortia have mitigated health inequity between urban and rural residents. We employed propensity score matching to mitigate selection bias among 9918 electronic medical records. We focused on two key areas: the effectiveness of medical consortia in reducing healthcare burdens and their influence on health equity, as indicated by the disparities in medical expenses between urban and rural residents. To obtain more detailed insights, we segmented medical expenses into low, medium, and high categories for both urban and rural residents and examined how medical consortia differentially affect health equity across these segments. Moreover, we evaluated whether the differences in referral effects on medical expenses between urban and rural residents can be explained by their varying disease structures and age distributions. We found that medical consortia can significantly reduce the medical burden on populations, but have limitations in improving health equity. The findings highlight a substantial reduction in medical expenses for urban populations. However, no significant reduction was observed in rural populations, with the low-medical-expense group experiencing an increased healthcare burden following the implementation of medical consortia. These findings are robust across various matching methods. Despite reducing healthcare burdens, medical consortia have not equalized health outcomes between urban and rural residents. Significant differences in the disease and age structures exist between urban and rural residents, which may account for the differing causal effects observed between them. Policymakers must prioritize health equity in healthcare reform and consider targeted interventions to address the distinct healthcare challenges of different socioeconomic groups.

China has long struggled with high medical costs and irrational drug pricing but has recently made significant progress by implementing drug negotiation strategies to effectively reduce the prices of targeted drugs. To accurately depict drug prices on a global scale, a cross-sectional time-series analysis was conducted in China using Multinational Integrated Data Analysis System data from the first quarter of 2017 to the fourth quarter of 2022. This analysis compared the prices of 140 price-negotiated innovative drugs across 15 countries using five distinct price indices-Average Price Index, Laspeyres, Paasche, Fisher, and Chained Laspeyres-aiming to address gaps in understanding China's negotiated drug prices globally. The five drug price index (DPI) showed general consistency and revealed significant variations in drug prices across countries. China's drug pricing reforms have successfully reduced drug costs and alleviated the financial burden on patients, offering insights for other developing countries. Drug price indices serve as valuable tools for monitoring prices and promoting transparency, while using PPPs may better reflect actual affordability and provide a more reasonable assessment.

Alcohol consumption poses significant public health challenges globally, with low- and middle-income countries (LMICs) experiencing a substantial burden from alcohol-related harm. However, the effectiveness of interventions to control alcohol consumption in LMICs remains understudied. This paper aims to investigate the effectiveness of alcohol regulatory interventions adopted in LMICs. A systematic search of MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science was conducted on 10 August 2024. The search strategy included terms related to regulatory interventions and their impact on alcohol consumption, health, and other related outcomes. Risk of bias was assessed using the National Institutes of Health, Cochrane Effective Practice and Organization of Care checklist, ISPOR-SDMD checklist, and CASP quality assessment tools, and a narrative synthesis was performed to summarize the review findings. Of the 169 full texts screened, 62 studies were included in this review. Most of the studies were conducted in upper-middle-income countries (n = 48, 77%), seven were from lower-middle-income countries, one from a low-income country, and others were combinations of the above. Sixty per cent of the included studies were of good quality. In terms of World Health Organization alcohol policy domains, 18 studies focused on restriction of physical availability, 11 on pricing, 1 on marketing, 21 on drink driving, and 11 on a combination of all policy domains. Alcohol consumption-related outcomes were reported in 26 studies, while health and other outcomes were reported in 25 and 14 studies, respectively. Restrictions on physical availability of alcohol were largely effective across all outcomes, while the pricing policy domain consistently demonstrated effectiveness in reducing alcohol consumption. The scarce evidence on marketing policy interventions was inconclusive; interventions targeting drink driving showed beneficial effects. The available evidence suggests that alcohol control policies are largely effective in LMICs. Further regular and statutory enforcement of these interventions is likely to improve their effectiveness.