According to hitherto available data, health expenditures in Pakistan are relatively low in international comparison. Data1F published by the World Health Organization (WHO) for the year 2005 shows a lack of Pakistani health expenditures in most indicators, compared to other low-income countries (LIC). To answer the question whether these results reflect the real situation in Pakistan or whether they exist due to statistical problems, Pakistan, for the first time, developed its National Health Accounts (NHA) in 2009. Only the availability of good estimates of health expenditures allows for evidence-based policymaking and therefore good governance.

The results clearly indicate that the situation in Pakistan is better than what was earlier estimated; however, the total health expenditure (THE) is still low compared to neighboring countries and other LIC. As a result, it is clear that the WHO health expenditure figures for Pakistan are understated, because they mainly comprise public and household out-of-pocket expenditures on health. Expenditures of many other entities, like military, cantonment boards, autonomous bodies, private hospitals, and so on, have not been taken into account in earlier estimations. Therefore, expenditure figures of NHA Pakistan are higher than those of WHO. Overall, the official NHA results show that THE is 27 percent higher than the WHO figure.

Furthermore, this paper cross-checks NHA results with other already available data sources on household expenditure. This comparison includes preliminary results of the Family Budget Survey (FBS), which also includes health items as well as National Accounts (NA) data. In line with this comparison, we calculate a raising factor that can be used for the adjustment of NHA results according to NA. The raised NHA result shows 102 percent higher out-of-pocket (OOP) spending on health; this would result in OOP health expenditures of $25.15 USD per capita (compared to only $12.45 USD per capita in the NHA estimation). This result, based on the NA figure with $33 USD THE per capita, leads to a different evaluation in international comparison, since it nearly reaches the level of India, with $37.5 USD and more than the average of all LIC with $27 USD.

China is transforming itself, and the world is adapting in response. Profound forces have reshaped the country's socioeconomic and political landscapes, but they have also brought challenges—growing pains—that China must face if it is to continue its upward trajectory.

Despite its successes, China is experiencing sharp growing pains. Rising levels of protest have accompanied the country's wrenching structural transformation. Corruption has prompted some observers to claim that the Chinese government is nothing short of a "predatory state." Legal reform continues to languish. Given that such challenges remain, can it be said that China's structural changes have succeeded? Or is the country trapped in transition?

"Growing Pains deserves the attention of every scholar interested in contemporary China." -Scott Kennedy, Indiana University

Growing Pains contains new analytical and empirical research from preeminent scholars working on contemporary China. These scholars identify which of the many problems thought to threaten China's reforms are not as serious as some interpreters claim, as well as those that have already been solved. Further, they point to other high-profile challenges, some of which truly are serious and loom on the horizon. With thoughtful, nuanced analysis, the contributors tackle thorny issues in China's ongoing reforms—employment, land policy, village elections, family planning, health care, social inequality, and environmental degradation—and use rich survey data and on-the-ground observation to assess the severity of the problems and the likelihood of near-term solutions.

Moving beyond the hype and hysteria that often characterize conversations about contemporary China, Growing Pains seeks to present not an optimistic or pessimistic perspective but rather an objective, empirically based view of the country's transition.

Examination copies: Desk, examination, or review copies can be requested through Stanford University Press.

Objective: To show the pattern of patient satisfaction with top-level delivery organizations (Level 2 and Level 3 hospitals), and using neo-institutionalism approach to explain the relatively low satisfaction and to explore the limitations with top providers, focusing on how to improve the competence of Level 2 and Level 3 hospitals at both the individual hospital level and the whole delivery system level.

Data Sources/Study Setting: The household survey by the National Bureau of Statistics in China in 2008; China Health Statistics Yearbooks.

Data Collection/Extraction Methods: The analysis uses a 2008 sample medical experiences of 5,036 residents from 17 provinces collected in a household survey by the National Bureau of Statistics in China. The linear regression model, the structural difference regression model, and the ordered probit model are used in our framework.

Principal Findings: The imbalance between the needs of patients and the limited competence of top-level providers, and the conflict between the business expansion and the limited competence of those providers are deeply and widely influenced by patterns of patient needs, the top providers’ expansion, and the institutional environment.

Conclusions: In order to effectively respond to patient needs, top and lower level providers need to set their own individual priorities. The government needs to improve institutional arrangements to respond to patient needs with the development of a fair and appropriate reimbursement and compensation pricing mechanism, and with further evaluation of top level providers’ advanced and limited health services.

Since 1978, China has been primarily market-focused in its provision of health care and social services. The market-driven health care system has been characterized by perverse incentives for individual providers, patients, and hospitals that are inducing improper provision of care: overprescription of pharmaceuticals and high-tech testing, lack of effective primary care and gatekeeping, and competition for patients instead of referral. The national health care reform document that was made public in April 2009 recognizes this failure of the market in health care in China. The document suggests potential policies for improvement on the current system that are focused primarily on a targeted increase in government funding and an increased, changing role for the government. We assess the potential of this national health care reform to achieve the stated goals, and conclude that the reform as designed is necessary but insufficient. For the reform to meet its goals, the promised increase in funding should be accompanied by improved data collection, regional piloting, and a strong regulatory and purchasing role for the government in aligning incentives for individual and institutional payers, providers, and patients.

Many Chinese express dissatisfaction with their healthcare system with the popular phrase Kan bing nan, kan bing gui (“medical treatment is difficult to access and expensive”). Critics have cited inefficiencies in delivery and poor quality of services.  Determining the pattern of patient satisfaction with health services in China—and the causes of patient dissatisfaction—may help to improve health care not only in China but in countries in similar predicaments throughout the world.

Using data from a sample of 5,036 residents from 17 provinces collected in a 2008 household survey by the National Bureau of Statistics of China, we analyze the patterns of patient preferences, concerns, and satisfaction among six social groups, classified by socioeconomic status including education level, income, and type of employment.

From regression results we conclude that the gap between what patients predict their service will entail and what they perceive the service actually did entail is the key determinant of lower satisfaction, especially for patients who care most about the quality of service and patients with higher social positions. Patients from lower social groups are more concerned with price and the attitudes of medical professionals, and generally express higher satisfaction with their health care experiences than their wealthier peers, despite receiving lower-level services. Patients with higher social positions are more concerned with the technical competence and quality of providers, and struggle with what they perceive as a lack of freedom to purchase and receive their desired services, as well as long waiting times and poor physician-patient interactions. These patterns of patient satisfaction appear to be the consequence of China’s unreliable basic delivery system, lack of advanced health service supply, and distorted health market. We discuss how what we have learned about patients’ dissatisfaction can be used to restructure the delivery system to better meet and shape patients’ needs.