The Role and Scope of Private Medical Practice in China. Lim Meng Kin Yang Hui, Zhang Tuohong Zhou Zijun Feng Wen Chen Yude

Transcription

1 The Role and Scope of Private Medical Practice in China Lim Meng Kin Yang Hui, Zhang Tuohong Zhou Zijun Feng Wen Chen Yude March 2002

2

3 Contents Page List of tables List of figures Acknowledgements Abstract i i ii iii Chapter 1. Introduction 1 Chapter 2. Methodology 4 Chapter 3. Results 1. Main findings from official sources Household questionnaire survey Doctors questionnaire survey Residents focus groups Doctors focus groups Interviews with stakeholders 50 Chapter 4. Discussion 60 Chapter 5. Conclusion and recommendations 70 Annexes A. Sample of household questionnaire A1-9 B. Sample of doctors questionnaire B1-4 C. Official national documents on private medical practice C1-4 D. Official provincial documents on private medical practice D1-4 E. Analyses of household questionnaire survey E1-95 F. Analyses of doctors questionnaire survey F1-18

4

5 List of tables and figures Tables Page 1. Economic development in China by province, Study provinces and the respective cities and counties 6 3. Basic statistics compiled from official sources for study provinces, cities and counties 17 (1999) 4. Profile of household respondents by provinces and types of residential area Health care utilization in the past 12 months Health care facility visited in the past 12 months Multivariate analysis for past health care utilization Multivariate analysis for unmet need due to any reasons Main reason for the unmet need Multivariate analysis for unmet need due to cost Genuine unmet need, defined as those who needed to see a doctor but did not get to see 22 any doctor at all in the last 12 months 12. Factors that independently affecting genuine unmet need in the last 12-month Factors independently affecting utilization of private clinics The most common conditions (top 5) seen at the various health care facilities Respondents who answered questions on ratings of their experiences with health care 24 facilities 16. Key dimensions of patient satisfaction for outpatient clinic Comparison of key domains of patient satisfaction for outpatient clinic between public and 27 private clinic visitors 18. Comparison of specific items of patient satisfaction, in which public clinics fared better 27 than private clinics 19. Factors influencing choice of doctors Respondents evaluation of the health care system Opinions of residents in urban and rural areas toward several statements (% agree and 31 strongly agree) 22. Multivariate analysis for being in favor of setting up more private hospitals 31 (% agree and strongly agree) 23. Multivariate analysis for being in favor of setting up more private clinics 32 (% agree and strongly agree) 24. Profile of doctors by practice settings Profile of doctors by provinces and urban/rural area Overall rating of the present health care system Opinions towards health care system Need to encourage more private clinics Part time private medical practice for public doctors Satisfaction with current medical practice Percentage who say health care costs are too high and unaffordable 62 Figures 1. Geographical location of the three study provinces in China 4 2. Typical sampling frame for province 8 3. Structure of the household questionnaire 9 4. Distribution of doctors surveyed in each province Comparison of experiences at private clinics and public clinics Comparison of experiences at private and public clinics (only rural residents) Comparison of experiences at private and public clinics (only urban residents) 29 i

6 Acknowledgements Funding for this study was provided by the United Nations Development Program (UNDP) and the World Health Organization (WHO). The cooperation and support of the Ministry of Health (MOH) China, and the Health Bureaus of Guangdong, Shanxi and Sichuan Provinces are gratefully acknowledged. The opinions expressed in this document, however, are entirely those of the authors and do not reflect the views of the abovementioned organizations or the institutions they individually represent. ii

7 Abstract The objective of this study was to gather quantitative and qualitative data so as to facilitate evidence-based policy making in relation to the development and growth of private medical practice in China. The study, carried out in the provinces of Guangdong, Shanxi and Sichuan, consisted of: questionnaire surveys administered to household residents and doctors; focus groups conducted with residents and doctors; and interviews with key stakeholders, namely government health officials, private and public sector health care managers and private health care investors. We found broad consensus regarding the useful and complementary role that private medical practice plays in China s health care system, but there were serious concerns about the poor regulatory environment as well. Dissatisfaction with the high costs, poor staff attitudes, and general inefficiency of the public health care system appear to be driving patients, both urban and rural, to seek cheaper but lower quality care from solo private practitioners. Our findings point to the need to address issues of effective regulation, equitable access, affordable costs, quality care and patient safety. A key policy challenge for the Ministry of Health China will be to determine the framework for future growth and development of the private health care sector, including the appropriate public-private mix that will maximize efficiency gains while maintaining the basic premise of equitable health care for all. We conclude with a list of specific recommendations for action. iii

8

9 Chapter 1. Introduction Chapter 1 Introduction China s bold market reforms which began in the 1980s have contributed to unprecedented economic growth benefiting the lives of millions of people. However, they have also affected the health care of its citizens in ways that are still being understood. One consequence is the re-emergence and proliferation of private medical practice. It is not clear what the true extent of private medical practice in the country is at the moment, much less what the appropriate public-private mix should be. Of particular concern are those situations where public providers have imposed user charges, leaving few options for those without the ability to pay. The development of the private health care sector, and the path that privatization will take within the pubic sector, are likely to impact on the success or failure of ongoing health care reforms. Yet, little information is available (e.g. what services are being offered, at what cost, to whom, and what controls are in place) to inform and guide policy-makers with respect to the role and scope of private medical practice in China, and the appropriate framework for its development. Research is also needed to elucidate the views and perspectives of key stakeholders -- consumers, practitioners, health care managers, investors, and officials -- who collectively (driven by differing motives and incentives) shape China s health care system. A collaborative study was thus undertaken to generate information that will support evidence-based policy formulation with respect to the future development of private medical practice in China. The study, commissioned by UNDP, WHO, and MOH China, was carried out in three provinces --Guangdong, Shanxi and Sichuan. The research team was led by Dr.Lim Meng Kin (WHO International Consultant) and comprised Dr. Yang Hui, Dr. Zhang Tuohong, Dr. Zhou Zijun and Dr. Feng Wen (all from Peking University), and Dr. Chen Yude (Ministry of Health). The provincial research collaborators were Dr. Chen Shaoxian (Guangdong University), Dr. Liu Yi (Sichuan University), and Dr. Zhen Jianzhong (Shanxi Medical University). Objective The objective of the study was to gather information to facilitate evidencebased policy making in relation to the development and growth of private medical practice in China. 1

10 Chapter 1. Introduction Research questions Specifically, the study sought to shed light on: Research activities the current situation with respect to private medical practice in the three provinces; the reasons why consumers use private medical services; the affordability of private medical services to consumers, compared to pubic medical services; the willingness and ability of consumers to pay for private medical services; the expectations and attitudes of practitioners, consumers and health officials towards private medical practice; the attitudes and opinions of practitioners, consumers and health officials on part-time private medical practice for doctors in the public health care system; the regulatory mechanisms currently used to permit private medical practice; and the attitudes and opinions of practitioners, consumers and health officials on the necessary controls for private medical practice in China. The following research activities were carried out: interviewer-administered questionnaire survey of 3600 households in the three study provinces, and involving both rural and urban areas; self-administered questionnaire survey of 720 medical practitioners in the three provinces, including both rural and urban areas, and public and private sectors; a total of 24 focus group sessions for patients and practitioners in the three provinces, including both rural and urban areas; interviews with selected key informants, namely health officials, health care managers in both the public and private sectors, and private health care investors in all three provinces; and review of documents and compilation of additional data obtained from MOH and the respective health bureaus of the three provinces. The study took one year (January to December 2001) to complete. The preliminary results were presented to MOH officials, local experts and academics at a workshop held on 1 March 2002 at Peking University, during which valuable feedback and constructive comments were received. 2

11 Chapter 1. Introduction Organization of report. This report is organized into five chapters, beginning with this introductory chapter on why the project was carried out, and what the research questions and activities were. Chapter two expands on how the study was carried out, including the methodology for data collection and analysis. Chapter three reports on the main findings in six parts, namely: from official sources, from the household questionnaire survey; from the doctors questionnaire survey; from the residents focus groups; from the doctors focus groups; and from the interviews with key informants. Chapter four synthesizes the salient findings, and explores the key policy implications. Chapter five concludes with a list of recommendations for action. As far as possible, details are banished to the Annexes which are found at the end of the report. These include samples of the questionnaires for the household and doctors surveys; listings of the official documents pertaining to private medical practice issued by the national and provincial authorities; and the detailed analyses for the household and doctors surveys. 3

12 Chapter 2. Methodology Chapter 2 Methodology Data collection A combination of approaches, both quantitative and qualitative, was used to generate the required information. The data collection methods included: questionnaire survey, focus group, interviews with key informants (health care managers, health officials and investors), review of official documents Selection of study provinces We purposefully selected three geographically disparate provinces, namely Guangdong, Shanxi and Sichuan for study, based on their different stages of economic development, and the availability of suitable research collaborators in the provinces. Figure 1: Geographical location of the three study provinces in China Guangdong Area: sq. km Population: 71 million GDP per capita US$ 1354 Shanxi Area: sq. km Population: 32 million GDP per capita US$ 612 Sichuan Area: sq. km. Population: 84 million GDP per capita US$ 527 4

13 Chapter 2. Methodology Guangdong, situated in the southern-most coastal region of China, has the distinction of being one of two provinces that were first opened to foreign direct investments in 1980, and hosting three of China s four special economic zones. Its high degree of autonomy to handle its own economic affairs has enabled it to surge ahead of others economically. Shanxi is a landlocked province noted for its coal and electric power industry, situated along the middle reaches of the Yellow River in the western part of north China, while Sichuan is a largely agricultural province located in the Upper Yangtze Valley in the southwestern part of the country. In terms of per capita GDP, Guangdong ranks fifth in China, compared to Shanxi (seventeenth) and Sichuan (twenty-fifth) (Table 1). Table 1. Economic development in China by province, 1998 Ranking Province GDP/Per Capita (US$) Population (million) 1 Shanghai 3, Beijing 2, Tianjin 1, Zhejiang 1, Guangdong 1, Fujian 1, Jiangsu 1, Liaoning 1, Shandong Heilongjiang Hebei Hubei Xinjiang Hainan Jilin Mongolia Interior Shanxi Hunan Henan Chongqing Anhui Jiangxi Qinghai Yunnan Sichuan Ningxia Guangxi Shaanxi Tibet Gansu Guizhou *Source: China Human Development Report, UNDP, Statistical information according to Statistical Yearbook of China,

14 Chapter 2. Methodology Selection of City/County Within each province, two rural and two urban sites were purposefully selected for study. This was done in close consultation with the respective provincial health bureaus, and included site visits by the research team to determine their suitability for study. 1. Questionnaire Survey Two separate questionnaire surveys were conducted, one for households and one for doctors. a. Household questionnaire survey An interviewer-administered questionnaire survey was carried out on a total of 3600 households (i.e each) in the three study provinces. Both rural and urban residential areas (i.e. 600 each) were covered. Population The household questionnaire was administered to heads of household or equivalent -- defined as any person living in the house, male or female, aged 18 years or more, and who is a Chinese permanent resident. Selection was determined by multi-stage cluster sampling, as follows: The health bureaus of the three Provinces were each asked to suggest urban cities and rural counties that are fairly typical of the province, and known to have private medical practice (clinics, and preferably hospitals as well although it was understood that the latter would be hard to find in the rural areas). Another criterion was that support was likely to be forthcoming from the local government and health department officials for such a study. The following list was arrived at: Table 2: Study provinces and the respective cities and counties Study province Guangdong Shanxi Sichuan (Population figures 1999) City (population) Shenzhen (1,200,000) Taiyuan (3,000,000 Leshan (3,450,000) County (population) Haifeng (710,000) Yangqu (140,000) Weiyuan (750,000) 6

15 Chapter 2. Methodology Selection of District/Township Two urban districts and two rural townships from each city or county respectively were then randomly selected from a list of all districts/townships, arranged from the biggest to the smallest according to population size, as follows: Cumulative population was computed for both lists, from the first district/township to the last. The first district (for city) or township (for county) respectively was selected based on the cumulative population that was closest to a random number generated. The second district or township respectively was selected based on the cumulative population which was closest to the midpoint between the first district/township chosen and the final cumulative population. The names of the two districts or townships were then affirmed by the local health department. Selection of residential area Residential areas were defined according to the residential committees in charge of these areas. Within each city or county, two urban residential committees and two rural village committees were randomly selected. The method of the selection was the same as for the district or township. The households under the jurisdiction of the residential/village committee would constitute the cluster of households to be studied. Selection of household The target sample population was 150 households from the total number of households within the jurisdiction of each residential committee or village committee. To cater for non-response, 180 households were randomly selected from each, as follows: The list of households was compiled based on house number, block, and/or known size of family. As the total number of families in the community or village was known, the sampling interval was determined by dividing the number of families by 180. The first household was selected on the basis of a computer-generated random number. The rest of the households were then determined according to the sampling interval. The names of heads of households and their addresses were then recorded. The last 30 households were designated as reserve households, for replacing nonresponding households if necessary. No replacements were used once the number of households interviewed had reached 150. Selection of respondent One respondent per household was interviewed. The inclusion criteria were: living in the household, regardless of residential registration; either male or female; and 18 years and older. The exclusion criteria were: below 18 years of age; mentally or cognitively impaired; too sick or weak to answer questions; unable to answer questions because of other reasons, e.g. physical impairments; and inability to use mandarin or for any other reason, unable to communicate with interviewer. 7

16 Chapter 2. Methodology The head of household was defined as either parent (father or mother) of a nuclear family. Should the head of household be unavailable, any other person who fulfills the above criteria was interviewed instead. The sampling frame was arrived at thus: (see Figure 2): 3600 households in three provinces, 1200 households in each province. 600 households in each county or city. 300 households in each district or township. 150 households in each residential area. Figure 2. Typical sampling frame for province PROVINCE CITY COUNTY District 1 District 2 Township 1 Township 2 Residential committee 1 (150 households) Residential committee 1 (150 households) Village committee 1 (150 households) Village committee 1 (150 households) Residential committee 2 (150 households) Residential committee 2 (150 households) Village committee 2 (150 households) Village committee 2 (150 households) Sample size The sample size of 600 for each city (= urban area) or county (= rural area) was based on a precision target of 95% level of confidence. Survey Instrument A locally-contextualized questionnaire was developed (see Annex A for sample). In addition to ascertaining the health seeking behavior of residents, the questionnaire contained customized question sets designed to gauge respondents level of satisfaction with the quality of care and services received from four groups of providers, i.e. Public hospital (inpatient care) Private hospital (inpatient care) Public clinic (outpatient care) 8

17 Chapter 2. Methodology Private clinic (outpatient care) The questions asked covered the full spectrum of patient experiences (ranging from satisfaction with providers to ratings of quality of services) as well as opinions on pertinent issues (see Figure 3). Figure 3. Structure of the household questionnaire 1. Screening question Opinions on 2. a. health care in general b. private medical practice Rating Ranking Agreement Open-ended Experience of A : Public hospital B : Private hospital C : Public clinic D. Private clinic Satisfaction with: Accessibility Cost Responsiveness Service quality Medical care quality Outcome Overall rating 3. Socio-demographic data A 5-point Likert-style response scale was used, which had the advantage of allowing for additive scoring of individual items as well as the derivation of summary indices or overall scores for specific domains under study. Well-established techniques founded on psychometric theory and addressing well-known sources of bias such as social desirability, reward and reinforcement effect, cognitive dissonance/incongruity effect, and response set bias, were incorporated into the design of the questionnaire. The questionnaire was designed in English, translated into Chinese, and then back-translated into English and the two versions harmonized. The questions were framed in such a way as to be sensitive to the nuances of the Chinese (mandarin) language. Only the Chinese version was used in the fieldwork. It was pre-tested with a random sample of 10 households in Beijing and further refined before final printing. Definition of private practice The definition of private hospital and private clinic was based on 9

18 Chapter 2. Methodology ownership. All non-governmental institutions were defined as private. The definition of private doctor is based on the employer being nongovernment, or self. Hence, a doctor in solo practice in an individually owned private clinic is a private doctor. The same goes for a doctor employed by a private hospital. Interviewers The questionnaires were administered by medical students who had received the requisite training. Fieldwork was undertaken under the supervision of the research collaborators from the three provincial universities, during their vacation in August Consent Participation was strictly voluntary. Invitations were made through letter, followed by actual house visits. Participants were assured that all information obtained would be treated with the strictest privacy and confidentiality. b. Doctors questionnaire survey A self-administered questionnaire survey was carried out on a total of 720 practitioners in the three study provinces. Doctors from both rural and urban health facilities were covered, as well as the public and private sectors. Population The doctors were conveniently selected from the public and private hospitals and clinics located at or near the sites of the household survey. The health facilities and doctors were non-randomly selected in consultation with the local health bureaus, according to the following criteria: Urban public hospital: hospital nearest the household survey site Urban private hospital: hospital nearest the household survey site Rural public hospital the county People s Hospital. Rural private hospital: one or more private hospitals in the county, until the required number of doctors was met. Urban public outpatients clinics: community hospital at the household survey site. Urban private clinics: private clinics in the vicinity of household survey site Rural public clinics: township health center at the household survey site. Rural private clinics: private clinics in the county. 10

19 Chapter 2. Methodology Within the larger facilities (pubic and private hospitals) the doctors participating in the study were chosen from among the various departments by the hospital director. For the smaller rural and urban private clinics, private doctors in private clinics were nominated by officials of the Health Bureau. The doctors recruited at each facility were assembled at a single location, given instructions for filling out questionnaires by the researchers themselves, and asked to fill out the survey forms independently. Anonymity and confidentiality were assured. Completed questionnaires were collected on the spot by researchers. A target number of 240 doctors in each province were surveyed in rural and 120 in urban areas (Figure 4). Figure 4: Distribution of doctors surveyed in each province Province City County Private (N=60) Public (N=60) Private (N=60) Public (N=60) As it turned out, 656 questionnaires (Guangdong 240, Shanxi 202 and Sichuan 214) were completed and entered into the analysis (see Annex F). Survey Instrument The self-administered questionnaire (see Annex B for sample) used a similar 5- point Likert-scale as for the household questionnaire. Questions covered the following areas: General opinion on the health care system Perceived problems with the health care system Opinion towards public and private practice Individual satisfaction with career and professional development Demographic data and general information including medical education. The questionnaire was designed in English, translated into Chinese, and then back translated into English. Both versions were harmonized before printing, but only the Chinese version was used in the fieldwork. 11

20 Chapter 2. Methodology 2. Focus Groups Focus groups were conducted for both residents and doctors: a total of 12 focus groups was conducted for residents in the three provinces, and covering both rural and urban areas a total of 12 focus group sessions was conducted for doctors in the three provinces, and covering both rural and urban areas. a. Residents Focus Groups Focus groups, designed to elicit in-depth insights and an understanding of motivations and perceptions of participants, were conducted for each of the residential areas surveyed. Two focus groups were conducted for each area. Participants were selected upon recommendation of the respective residents committees. There were on average, 10 participants to each group. The provincial professors on the research team of collaborators acted as moderators. The discussions centered on the following themes: Problems encountered with the existing health care system Opinion on role of private medical practice in their province Opinion on government encouragement of the private health care sector Opinion on the need for regulation of private sectors Opinion on part time work of public doctors in private sector b. Doctors Focus Groups Two focus groups were similarly conducted for doctors in each of the survey areas. Participants were selected upon nomination of the respective health bureaus. There were on average, 10 participants in each group, which invariably had a mix of private and public practitioners. The provincial professors on the research team of collaborators acted as moderators. Doctors focus groups explored the following issues: Role of private medical practice Cost and quality issues Whether government should encourage more private health facilities Opinion on a range of issues including medical advertisements, part-time private practice for public doctors and regulation of the health sector. 12

21 Chapter 2. Methodology 3. Interviews with selected key informants The following selected key informants were personally interviewed by the provincial professors on the research collaboration team in each of the three provinces. 8 selected health officials ((3 from Guangdong, 3 from Sichuan, and 2 from Shanxi) 6 selected private health care investors (2 from each province): 15 selected health care facility managers (5 from Shanxi, 4 from Guangdong and 4 from Sichuan; 8 are from the private sector, while 5 are from the public sector) The following issues were explored: Role of private medical practice Whether government should encourage growth of the private sector Part time work of public doctors in private sector Regulation of the health sector Other concerns. 4. Review of documents from official sources Additional information was obtained from a number of official documents pertaining to private medical practice in China. These comprised national documents obtained from the MOH (Department of Healthcare Management and Centre of Health Statistic Information) (see Annex C) and provincial documents obtained from the Provincial Health Bureaus and City/County Health Bureaus (see Annex D). The aim was to gain an understanding of the policy contextual background to the development of private medical practice in China. Healthcare statistics (1995 to 2000) were also obtained, as was information relating to private healthcare facilities and foreign joint venture healthcare facilities. Training To achieve common ground among all research team members and the provincial research collaborators, training workshops were conducted by the WHO consultant at Peking University, on the objective and design of the study, the techniques and methodologies for questionnaire design and analysis, and practical tips on the conduct of questionnaire surveys, focus groups and interviews. The provincial researchers, in turn, conducted training workshops for field investigators (medical students from the respective medical universities) in the provinces. As part of the provincial investigators training, a pilot study involving 50 households was carried out, but the results were excluded from the database of the main survey. 13

22 Chapter 2. Methodology All field investigators (medical students) for the surveys were required to pass a test at the end of the training. University teaching staff were deployed as supervisors of the household survey. They took charge of the organization, checking of the completed questionnaires, and field re-investigations, where necessary. Quality control Data integrity was assured by quality control mechanisms throughout all phases of data collection, data entry, and data analysis. Trained field investigators (medical students) administered all the questionnaires. Supervisors and interviewers of household survey were responsible for the reliability and completeness of the questionnaires. Interviewers were required to check the completed questionnaires each day while the supervisors checked the completed questionnaires at the end of each day. If necessary, interviewers had to reinvestigate to rectify any mistakes made. For quality control, supervisors personally re-investigated 5% of households. Data entry and analysis Computer data entry using Microsoft Excel was double-checked for data entry errors. If a discrepancy was found in the questionnaire during data entry, the original questionnaire was returned to the field investigators for rectification. Data analysis involved univariate, bivariate, and multivariate analyses using SPSS version

23 Chapter 3. Results part 1 Chapter 3 Results Part 1: Main findings from official sources Twenty years have passed since the legalization of private medical practice in China. In this section, we briefly summarize the status of private medical practice in China according to information from official sources. The re-emergence and official sanctioning of private medical practice (which was banned during the cultural revolution) apparently coincided with the dismantling of the rural Cooperative Medical System (CMS), the latter occurring along with the dismantling of other administrative structures as a consequence of China s sweeping economic reforms. CMS coverage was so markedly reduced that to survive, the vast majority of village clinics had to be transformed into privately owned ones, operating on a fee-for-service basis. At the same time, because of the lack of public funding, many rural health workers -- particularly rural doctors already dissatisfied with poor working conditions were drawn to the urban areas by better remuneration and working conditions. In the urban areas, existing insurance schemes experienced serious financial difficulties, aggravated by the rapid diffusion of expensive, high-tech medical care, poor awareness and understanding of the inflationary impact of market-based medicine, and insufficient risk-pooling protection schemes for employees of local government and state-run enterprises who were previously enjoying free care. Despite numerous adhoc cost-containment measures in the 1980s and risk-pooling measures since 1992, as well as decentralization of responsibility for the health insurance funds from the central to the provincial level since 1998, major problems remain. It is against this backdrop that fee-for-service private medical practice has flourished in the cities. As early as 1980, the Ministry of Health reviewed the situation in a landmark Report on the Granting of Permission for Solo Private Medical Practice which recommended legalizing private medical practice and regulating it strictly. In 1985, the State Council directed that private medical practice should be encouraged and in 1987, the State Bureau of Industry and Commerce Administration granted permission to public sector health professionals to own and operate private medical clinics after their retirement from public service. In 1988, the Ministry of Health and the State Bureau of Traditional Medicine Administration jointly issued a set of regulations spelling out the criteria for the establishment of private medical practices. Included in these regulations were details of the licensing process and the penalties for non-compliance. In 1989, the Ministry of Health allowed part-time private medical practice in public health care facilities. In 1992 the State Pricing Bureau and the Ministry of Finance jointly promulgated the standard administration fees for the establishment of private medical facilities. 15

24 Chapter 3. Results part 1 Between 1993 and 1994 the Ministry of Health and the State Bureau of Industry and Commence jointly laid down the Methods of Administration of Advertisements for Medical Services and Medications. In 1994, the Ministry of Health issued Basic Standards Of Healthcare Facilities (Draft) and Key Principles Of Distribution Of Healthcare Facilities, but made no mention of how private health facilities would fit into the overall master plan. In 1997, the State General Bureau of Industry and Commence and the State General Bureau of Tax issued separate requirements for registration of private medical practice and taxation. In 1998, the Ministry of Health issued a regulation that made it illegal to operate a medical practice without a license from the State Bureau of Tax and urged all private doctors and health care facilities to comply with tax registration. In the same year, the Ministry of Health issued The Notice of Enhanced Management of Employment of Social Health Workers which regulated the management and employment of non-institutional medical health workers. Since 2000, the Ministry of Health has required all medical facilities to be registered as either non-profit or for profit entities. A list of relevant official documents reviewed by the study team is given in Annex C. In addition, we reviewed a number of regulations on private medical practice promulgated by the Provincial governments. A list of these documents in given in Annex D. It can be seen that there are adequate rules and regulations already laid down, ranging from prescribed examinations and minimum standards for the licensing of medical practitioners, through the minimum standards and monitoring of health care facilities, to the fees and taxes levied by different government agencies. A point to note is the large number of agencies involved in the issuing and administration of the regulations.. Table 3 shows additional statistics compiled from official sources, which reveal some basic information on the status of health care facilities in the three study provinces, as well as the cities/counties that were studied. The combined population of the three study provinces accounted for one sixth of total Chinese population. Based on GDP and average individual income, Guangdong is economically more developed than Shanxi and Sichuan. Urban residents have also much higher income than rural residents. Private health care providers can be divided into private hospitals and private clinics. There are altogether 5792 public hospitals and 192 private hospitals in the three provinces combined. Private hospitals comprise only a small percentage (3.3%) of the total number of hospitals. Sichuan has the most number of private 16

25 Chapter 3. Results part 1 hospitals (84), followed by Guangdong (64) and Shanxi (44). As for private clinics, there are 14,665 in Sichuan, 8455 in Shanxi, and an indeterminate number in Guangdong. Among the urban and rural sites studied in each province (data for the entire province were unavailable), the highest concentration of private clinics is found in Taiyuan city in Shanxi Province (4.4 per 10,000 population), followed by Shenzhen city in Guangdong Province (2.6 per 10,000 population) and Leshan city (1.8 per 10,000 population) in Sichuan Province. The highest concentration of private clinics among the rural areas is in Yangqu County in Shanxi Province (2.1 per 10,000 population) followed by Haifeng in Guangdong Province and Weiyuan in Sichuan, which have the same concentration (1.3 per 10,000 population). Table 3. Basic statistics compiled from official sources for study provinces, cities and counties (1999) Guangdong Shanxi Sichuan Province Shenzhen City Haifeng County Province Taiyuan City Yangqu County Province Leshan City Weiyuan County Area (10,000km 2 ) Population (10,000) Average individual income 9125(U*) (U) (U) (R*) 1772(R) 1789(R) GDP (yuan) ? No. medical institutions# No. hospitals Public hospitals Private hospitals Private hospitals per ,000 pop. No. private clinics No. per 10,000 pop Health Manpower ? Private health manpower ? Private health manpower per 10,000 pop. Consultations (10,000) Private (10,000) ?? 0.9? Private consultation per 10,000 pop * U- Urban areas, R- Rural areas # does not include private clinics.? = data unavailable 17

26 Chapter 3. Result part 2 Part 2: Main findings from the household questionnaire survey Response rate There were 3730 respondents to the household questionnaire, giving a response rate of 95.6%. Profile of respondents Overall, females (55%) outnumbered males (45%), a pattern that was consistent for all three provinces and for both rural and urban residents (Table 4). The mean age was 45 years (SD=15.4years). Half of the respondents had attained a minimum educational standard of junior middle school. The vast majority (83%) were married. Farmers constituted the largest occupational group (40%) followed by retirees (16%). In the rural areas, farmers alone comprised 78% of the respondents. 71% of respondents had no health insurance of any kind. The percentage of uninsured was much higher in the rural (90%) than in urban areas (51%). The median annual household income range was 5000 to 9999 yuan. Guangdong residents were the richest: 51% of households had with annual income exceeding yuan. This was about 5 times more than in Shanxi (10%) and 9 times more than in Sichuan (6%). Sichuan residents were the poorest, having the highest number of households with annual income of less than 2000 yuan (19%), compared to Shanxi (14%) and Guangdong (6%). Utilization of medical services 64%.of respondents visited a doctor during the past 12 months. 82% of these visits were made within the last 6 months. There was no significant difference between urban (65%) and rural (62%) residents in their utilization of health care services in the past 12 months (Table 5). About 53% of the last visit was to public hospital (Table 6). However, it should be noted that most of these visits were outpatient visits as many of the public outpatient clinics are located within public hospitals. 18

27 Chapter 3. Result part 2 Table 4. Profile of household respondents by province and residential area Socio-demographic Variables All (N=3730) Province Guangdong (N=1200) Shanxi (N=1200) Sichuan (N=1330) Residential area Urban (N=1864) Rural (N=1866) Gender Female Male Age Mean/SD 45.0 (15.4) 38.0 (14.1) 48.1 (14.8) 48.4 (14.9) 46.0 (16.5) 43.9 (14.1) Educational level No education Primary school Junior middle school Senior middle school Junior college Bachelor degree & above Marital status Never married Married Divorced/widowed/others (Missing) 0.1 Occupation Government officer Manager/ executive Clerk/ serviceman Self-employed Farmer Unemployed Student/part timer/others Retired Health insurance Yes State health insurance Cooperative health insurance Company health insurance No Annual household income (Yuan) < and above Figures are in percentages; All socio-demographic variables (in the first column), except for gender, are significantly associated with province and type of residential area (p<0.001); 19

28 Chapter 3. Result part 2 Table 5. Health care utilization in the past 12 months Total Province Type of residential area Guangdong Shanxi Sichuan Urban Rural 2372 (63.6) 876 (73.0) 751 (62.6) 745 (56.0) 1213 (65.1) 1159 (62.1) Figures in brackets are in percentages Table 6. Health care facility last visited in the past 12 months Total Province Guangdong Residential area Shanxi Sichuan Urban Rural Private hospital Public hospital Private clinic Public clinic Figures are in percentages The final model of the multivariate analysis using Cox regression with the backward selection method revealed several sociodemographic factors that independently affected health care utilization in the past 12 months (Table 7). It showed that people living in Guangdong and Shanxi province, rural area, female, having health insurance, with poor self-reported health status, and earning higher income were more likely to use health services in the past 12 months. Table 7. Multivariate analysis for past health care utilization Variables RR & 95% CI Province Guangdong 1.30 ( ) Shanxi 1.14 ( ) Sichuan* 1.00 Type of area Urban 0.88 ( ) Rural* 1.00 Gender Male 0.89 ( ) Female* 1.00 Health insurance No 0.89 ( ) Yes* 1.00 Health status Very poor, poor, fair 1.37 ( ) Good and very good* 1.00 Income Less than ( ) ( ) ( ) ( ) and above* 1.00 Reference group 20

29 Chapter 3. Result part 2 Unmet need Half (50%) of the respondents experienced at least one occasion in the last 12 months when they did not get to see a doctor even though they needed to see one. Multivariate analysis showed the significant determinants of unmet need to be: Residents of Shanxi and Sichuan provinces, urban residents, higher education, poor health status, and lower household income (Table 8). Table 8. Multivariate analysis for unmet need due to any reasons Variables RR & 95% CI Province Guangdong* 1.00 Shanxi 1.41 ( ) Sichuan 1.10 ( ) Type of area Urban 1.16 ( ) Rural* 1.00 Education level No education* 1.00 Primary school 1.12 ( ) Junior middle school 1.20 ( ) Senior middle school 1.22 ( ) Junior college 1.46 ( ) Bachelor degree or above 1.54 ( ) Health status Very poor, poor, fair 1.43 ( ) Good and very good* 1.00 Income Less than ( ) ( ) ( ) ( ) and above* 1.00 * Reference group The main reason given for not visiting the doctor was cost (49%). The second most frequent reason given was I did not want to make a fuss of it (38%) -- indicating that many who decided to forgo seeing a doctor did so because they considered their conditions to be not serious or life-threatening (Table 9). This reason may also explain why people with higher education had higher percentage of unmet need (further analysis of the subgroup who said cost was the main reason did not show association with higher education). Table 9. Main reason for the unmet need The main reason for the unmet need were Cost too much 903 (48.8) Did not want to make a fuss 698 (37.7) Could not spare the time 96 (5.2) Other reasons 90 (4.9) The clinic/hospital was too far 23 (1.2) Poor attitude of health care staff 8 (0.4) (Figures in bracket are percentage) 21

30 Chapter 3. Result part 2 Among those who said that cost was the main reason for their unmet need (N=903), the significant influencing factors were province, type of area, health status, and annual household income. People of Shanxi and Sichuan, living in urban area, having poor health status, and lower income were more likely to have unmet need due to cost (Table 10). Table 10. Multivariate analysis for unmet need due to cost Variables RR & 95% CI Province Guangdong* 1.00 Shanxi 2.98 ( ) Sichuan 2.02 ( ) Type of area Urban 1.28 ( ) Rural* 1.00 Health status Very poor, poor, fair 1.81 ( ) Good and very good* 1.00 Income Less than ( ) ( ) ( ) ( ) and above* 1.00 * Reference group We further analyzed this group who experienced an episode of unmet need by dividing it into two subgroups, i.e. (a) unmet need, with no utilization of health care at all in last 12 months, and (b) unmet need, with utilization of health care on other occasions within the last 12 months. By eliminating the latter category, we arrived at a smaller subgroup of people (n = 613 or 16 % of total) who could truly be considered to have genuinely unmet need", as they did not enter the health care system at all for the whole year, despite a felt need to do so. The profiles of those in this category are shown in Table 11. Table 11. Genuine Unmet need, defined as those who needed to see a doctor but did not get to see any doctor at all in the last 12 months Characteristics Unmet need (due to any reason; N=613) Gender Male 46.8 Female 53.2 Provinces Guangdong 17.8 Shanxi 38.7 Sichuan 43.6 Type of area Urban 53.7 Rural 46.3 Figures are in percentages 22

31 Chapter 3. Result part 2 The final model of multivariate analysis using Cox regression (Table 12) showed that the significant factors influencing unmet need were: province (Shanxi>Sichuan>Guangdong), urban residential area, male gender, no health insurance and lower household income. Table 12. Factors that independently affecting genuine unmet need in the past 12- month Variables RR & 95% CI Province Guangdong* 1.00 Shanxi 2.23 ( ) Sichuan 1.90 ( ) Type of area Urban 1.58 ( ) Rural* 1.00 Gender Male* 1.00 Female 0.80 ( ) Health insurance No 1.24 ( ) Yes* Income Less than ( ) ( ) ( ) ( ) and above* 1.00 * Reference group Utilization of private medical services About 33% of household survey respondents reported that their last visit was to a private clinic. Only 5% sought treatment at a private hospital, and 1% was admitted to a private hospital. In view of the small number of patients treated at private hospitals, further comparative subgroup analysis was done only for private clinics and public clinics. The significant factors affecting the utilization of private clinics are shown in Table 13. People from Sichuan and Guangdong, rural areas, and having health insurance were more likely to visit private clinics. Table 13. Factors independently affecting utilization of private clinics Variables RR & 95% CI Province Guangdong 0.85 ( ) Shanxi 0.66 ( ) Sichuan* 1.00 Type of area Urban 0.56 ( ) Rural* 1.00 Health insurance Yes 1.18 ( ) No* 1.00 * Reference group 23

32 Chapter 3. Result part 2 Commonly seen conditions at private clinics As expected, relatively minor conditions like sore throat, common cold, upper respiratory tract infection, gastrointestinal disorders, and gynecological disorders constituted the main clinical conditions seen at both private and public clinics (Table 14). Patients with more serious conditions like hypertension and heart problems, pneumonia and other disorders of respiratory system, cerebrovascular disease, ear and gall bladder disorders tended to go to public hospitals. Table 14. The most common conditions (top 5) seen at the various health care facilities Rank Private hospital Public hospital Private clinics Public clinics 1 common cold 27.3 common cold 13.6 common cold 46.1 common cold reproductive disorders 6.4 gastroenteritis 4.3 gastroenteritis 4.2 phayrngitis phayrngitis 4.5 hypertension 4.2 influenza 3.8 hypertension gastroenteritis 4.5 musculoskeletal disorders 4.1 phayrngitis 3.6 gastroenteritis influenza 3.6 reproductive disorders Figures are in percentages 3.4 hypertension 1.8 reproductive disorders 3.0 Patient satisfaction: comparing experiences at private and public clinics 2876 respondents who visited at least one of the health care facilities (i.e. public hospital, private hospital, public clinic or private clinic) responded to questions on their level of satisfaction with their last encounter at these institutions (Table 15). Table 15. Respondents who answered questions on ratings of their experiences with health care facilities In the past 12-month All Province Residential area Guangdong Shanxi Sichuan Urban Rural Admitted to public hospital 298 (11.0) 123 (10.8) 97 (12.9) 78 (9.6%) 218 (16.7) 80 (5.7) *** Admitted to private hospital 35 (1.3) 32 (2.8) 2 (0.3) 1 (0.1) *** 29 (2.2) 6 (0.4) *** Visited public clinic 1460 (54.0) 422 (36.9) 568 (75.6) 470 (58.1) *** 894 (68.6) 566 (40.4) *** Visited private clinic 1083 (40.3) 469 (41.3) 223 (29.7) 391 (48.8) *** 350 (27.1) 733 (52.5) *** Figures in bracket are in percentages; *** P<