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Challenges for Primary Health Care Services

China, a large and rapidly developing middle-income country with a hospital-based service delivery system for its aging population, makes a suitable case study of efforts to promote PHC management. Over the past several decades, PHC use in China has significantly decreased relative to hospital-based care. This trend is a natural consequence of the country’s unprecedented increases in living standards and improvements in financial risk protection, which increase patients’ demand for quality care and spur self-referral to providers with higher-perceived quality like hospital outpatient departments.

The performance differences between PHC and hospital-based care are especially stark in China’s rural areas, where management of chronic diseases relies heavily on grassroots physicians, who have limited medical education and training. That is why Eggleston and her colleagues set out to provide new empirical evidence about the effectiveness of a program that promotes PHC management of hypertension and diabetes for rural Chinese. Part of the National Basic Public Health Service Program for rural Chinese, it financially rewards PHC grassroots physicians for managing residents with chronic diseases.

Collaborative Research in the Era of Great Power Competition

Eggleston’s co-authors include her colleagues at the Zhejiang Provincial Center for Disease Control and Prevention (Zhejiang CDC). Their study is the culmination of Eggleston’s multiyear collaborative research project with the Zhejiang CDC team, "Addressing Health Disparities in China," which looks to Tongxiang county in Zhejiang as a case study of China's responses to healthcare inequalities and population aging challenges in rural and urban areas. The project also involved two Stanford doctoral students who worked with Eggleston.

“This kind of collaboration, where we utilize the data that's available to answer an important question while respecting the privacy of the individuals and hopefully delivering benefits to them through more effective or affordable programs in the future perhaps is a promising model for researchers here and elsewhere to undertake,” she notes.

Disentangling the Effect of Primary Health Care Management

To study the program’s effectiveness, the researchers assembled a unique dataset linking individual-level administrative and health information between 2011 and 2015 for rural Chinese diagnosed with hypertension or diabetes in Tongxiang, a mostly rural county of Zhejiang province in southeast China. Collected by the Tongxiang CDC and Zhejiang CDC, the compiled database links basic demographic information, health insurance claims, PHC service logs, and health check-up records — four sets of data that are rarely linked and analyzed in combination in China healthcare research.

Targeting the program’s effects on healthcare utilization, spending, and health outcomes, Eggleston and her colleagues compare residents in neighboring villages that straddle township boundaries. These residents are similar in their individual and environmental characteristics that shape health care use but are subject to different PHC management practices. This “border sampling” allows the researchers to disentangle the effects of PHC management from other underlying spatial differences that impact health care utilization. For each township, the researchers use a management intensity index that reflects the cumulative efforts of PHC physicians to screen their communities and keep patients within the PHC management programs for controlling hypertension and diabetes. Each township’s experience with PHC management over the 5-year study period is thus a case study for rural China.

Net Value in Chronic Disease Management

The results are encouraging for China's investment in primary care management of chronic diseases. Eggleston and her colleagues find that patients residing in a village within a township with more intensive PHC management had a relative increase in PHC visits, fewer specialist visits, fewer hospital admissions, and lower spending compared to neighbors with less intensive management. They also tend to have better medication adherence and better health outcomes as measured by blood pressure control.

The results suggest that PHC chronic disease management in rural China improves net value in multiple ways — increasing PHC utilization, reducing avoidable hospitalizations, decreasing medical spending, and improving intermediate- and long-run health outcomes — all while leveraging existing resources rather than restricting care.

The findings also help inform investments in primary health care in LMICs. They highlight the latent potential of frontline healthcare workers in such settings to be more productive and show that financially rewarding these grassroots workers for managing residents with chronic diseases helps improve health outcomes. Moreover, they offer empirical evidence that supports the effectiveness of chronic disease management programs as part of broader regional initiatives to address population health.

The Walter H. Shorenstein Asia-Pacific Research Center (APARC) is pleased to invite applications for four types of fellowship in contemporary Asia studies for the 2022-23 academic year.

The Center offers postdoctoral fellowships that promote multidisciplinary research on contemporary Japan, contemporary Asia broadly defined, health or healthcare policy in the Asia-Pacific region, and a fellowship for experts on Southeast Asia. Learn more about each fellowship and its eligibility and specific application requirements:

Postdoctoral Fellowship on Contemporary Japan

Hosted by the Japan Program at APARC, the fellowship supports research on contemporary Japan in a broad range of disciplines including political science, economics, sociology, law, policy studies, and international relations. Appointments are for one year beginning in fall quarter 2022. The application deadline is January 3, 2022.
 

In this relatively well-insured population, annual health care utilization significantly increases primarily because of more intensive use of outpatient care at retirement. This increase in outpatient care stems from a decline in the patient cost-sharing rate, the reduced time constraints upon retirement, and the interaction of these factors with supply-side incentives such as prescribing antibiotics. There is no evidence of change in inpatient care at retirement.

The economics of medical expenditure growth and its interaction with population aging is of considerable policy importance for countries in all income groups. “Our findings may provide useful evidence as one consideration for policymakers in other cities in China and elsewhere looking to increase insurance benefits and control medical spending for burgeoning elderly populations.

This article was first published by the social and political economy portal IndiaSpend.

Women from poor households made about 235,000 fewer hospital visits compared to men for seven gender-neutral disease categories between January 2017 and October 2019, a new study analyzing a Rajasthan state health insurance scheme has estimated. The Bhamashah Swasthya Bima Yojana aims to provide health insurance to about 46 million persons living below the poverty line, as a step towards universal and equitable access to healthcare in the state, per the study.

Pascaline Dupas and Radhika Jain of Stanford University studied data of insurance claims from 4.2 million hospital visits under the Bhamashah scheme from its launch in December 2015 till October 2019, and the study was published as a National Bureau of Economic Research working paper. The study was conducted in partnership with the Rajasthan state government.

Women made up 45% of hospital visits under the Bhamashah scheme between January 2017 and October 2019, though their share in the population is 48%, per the study. The gender gap is starker for girls and older women. The share of girls in children aged under 10 years who visited the hospital under this insurance program was 33%, though their share of this age group's population is 47%; among those aged above 50 years, women are 51%, yet their share of hospital visits under this insurance program was 43%.

"We were struck by this discrepancy in the data. We were not expecting such a large [gender] difference," Dupas, an economist and professor at Stanford University, told IndiaSpend. In most other developed countries for which such data have been analyzed, subsidized healthcare usually caters to those who otherwise don't have access to it, added Jain, a postdoctoral fellow in Asia Health Policy at Stanford University, US.

This opinion piece was first published in the economics and policy portal Ideas for India.

Equity in healthcare is a key goal of health policy in India. Analyzing administrative data from Rajasthan, this article highlights substantial gender gaps in the utilization of subsidized hospital care under the state health insurance program. These disparities persist despite substantial program expansion and seem to be driven by households being less willing to allocate resources to female vis-à-vis male health.

Over the past 15 years, India’s central government and numerous state governments have put in place health insurance programmes that entitle low-income households to free healthcare at public and empanelled private hospitals. Health equity and universal health coverage are explicit goals of these programs. In new research, we study gender equity in the Bhamashah Swasthya Bima Yojana (BSBY)1 health insurance program, which was launched in the state of Rajasthan in 2015, and is similar in design to the national Pradhan Mantri Jan Arogya Yojana (PMJAY).

Our starting point is a dataset of insurance claims filed for all 4.2 million hospital visits between 2015 and 2019, including patient age, gender, residence address, hospital visited, dates of admission and discharge, and service(s) received. We geo-coded hospital locations and patient addresses, which allowed us to calculate proximity to hospitals and the distance traveled for every hospital visit. Finally, we linked the insurance data to the 2011 Census and data on three rounds of village-level (gram panchayat) elections. To our knowledge, the dataset we compiled from these various sources is the first dataset of its type in India and allows us to study care-seeking under insurance with unusual granularity.