Performance evaluations, trust and utilization of health care in China: understanding relationships between attitudes and health-related behaviour

Lead Research Organisation: University of Glasgow
Department Name: College of Social Sciences

Abstract

This interdisciplinary project establishes a new collaboration among UK researchers and a leading Chinese social research team, to conduct the first major study of Chinese people's attitudes towards their health care. The project's core theoretical contribution will be to understanding the relationships between attitudes and health-related behaviours, focussing particularly on how people evaluate their health system, their trust in doctors and the health system, and their utilization of preventive and curative health services. Previous quantitative research on China's health system has examined the influence on utilization of age and gender, incomes, insurance protection, distance to health service providers and perceived health care needs. Yet work done in other countries has shown that attitudes, including performance evaluations and trust, can impact on people's decisions about when and where to use health services. At the same time, qualitative studies in China have suggested that people are often critical of performance and that there is a crisis of trust in doctors and the health care system. Our project will be the first systematic study of these attitudes and how they influence utilization.
Beyond its contributions to understanding influences on utilization and thereby to health policy making in China and elsewhere, our project will contribute to political science by assessing the implications of health-related attitudes for government support and legitimacy. It will also benefit Chinese health policy makers through its findings on ordinary people's evaluations of the system. China's health system has experienced enormous transformations over the last thirty years affecting the lives of all its many citizens, but health policy making has been dominated by the concerns of elites. Although into the 21st century some of those elites--as well as international organizations and researchers--have criticized the health care system as unfair and costly, there has been little in-depth research on how the public view it.
Our study will combine focus groups with the first nationally-representative social survey to ask questions about health system performance and trust alongside socio-demographic characteristics, enabling factors, health needs, and health-related behaviours, especially utilization of preventive and curative health care services. It will produce a major dataset enabling UK and international researchers to study the relationships between attitudes and behaviour in the Chinese health care system. It will also develop social science research capacity in the UK and China by forging a new partnership among leading researchers in the field of Chinese public opinion and health survey research.
The project will be of use to international NGOs and organizations such as the World Bank and World Health Organization active in shaping health policy in China and in other developing countries. Our findings also have potential to impact on practices of the UK government's Department for International Development and the United Nations Development Programme because understanding health behaviours and improving health are vital to reducing global poverty. With health a key area for the Chinese government and central to national socio-economic development and political stability, our findings will also be of use to UK foreign and economic policy makers now increasingly engaging with this rising power.
Finally, China's growing wealth and aging population mean that health care services are expected to consume an increasing share of household incomes and national GDP, making China a major emerging health care market. Our examination of how socio-economic and demographic factors relate to attitudes and utilization of the health care system will be therefore be of value to British insurance and pharmaceutical firms as well as those involved in hospital provision.

Planned Impact

The non-academic beneficiaries of our research will be:
1. Practitioners and policy-makers in health policy and health system design and evaluation in China (e.g. Ministry of Health, National Development and Reform Commission where PI has strong contacts).
2. International organizations actively involved in supporting and evaluating China's health system reforms (and the achievement of Millennium Development Goals in China and other developing countries), such as the World Health Organization (WHO), World Bank and United Nations Development Programme (UNDP), particularly their Beijing offices; United Nations Research Institute for Social Development (UNRISD) and WHO offices in Geneva.
3. UK/Scottish government and EU policy makers working on bilateral projects or engaging more widely with China. These include UK Foreign and Commonwealth Office and the Departments for Business, Innovation and Skills (BIS) and International Development (DfID) which now works closely with the World Bank in China.
4. Companies investing in Chinese markets for the private provision of health insurance, production of pharmaceuticals, medical equipment and provision of hospital services (e.g. Synergy Health, whose CEO was part of a business delegation travelling with David Cameron to China in November 2010).
5. NGOs (charities and other third sector organizations) working to find ways to reduce unfairness in access to health care as well as to meet specific health care needs, for example of women, in developing countries.

Our research will benefit these users in the following ways:
1. Deepening and transforming understanding by scholars, practitioners and policy makers of the factors affecting health care utilization and other health-related behaviours in China. Our project has the potential to influence the course of international development and health care debates and policies through its insights on the relationships between attitudes and health-related behaviours.
2. Improving information for Chinese policy-makers and their domestic and international advisers in their current attempts to achieve the government's stated goals of providing basic health care for all and improving access. Our survey evidence on people's attitudes, values and preferences and their relationships with other socio-economic factors will inform health policy on many dimensions. It may help mobilize political support for carrying through health system reforms, improving regulation of health care delivery and insurance, and changing behaviour of service users and health professionals. Survey results and the insights gained through their detailed analysis have the capacity to influence policy agendas, change perceptions and attitudes, and influence the way issues are defined and framed and the values which are perceived to be at stake in health care reform.
3. Contributing to understanding of China and Chinese people's values and policy preferences as well as their support for government policies by UK government (FCO, BIS, DfID) and EU policy makers as well as wider civil society.
4. Contribute to the UK economy by enhancing businesses' understanding of China's markets for health care and health insurance. The opportunities in China for health sector investment (by UK and EU firms) are growing and our project will produce valuable new information on health consumers' attitudes and preferences as well as levels of insurance, health-related behaviours and health care utilization.
5. Helping development NGOs and international governmental organizations active in China and other developing countries to identify strategic priorities in the health care field and understand the policy context of health care delivery.

Publications

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Duckett J (2016) Does distrust in providers affect health-care utilization in China? in Health policy and planning

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Munro N (2013) Profiling the Victims: public awareness of pollution-related harm in China in Journal of Contemporary China

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Munro N (2017) Does Refusal Bias Influence the Measurement of Chinese Political Trust? in Journal of Contemporary China

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Munro N (2016) Explaining public satisfaction with health-care systems: findings from a nationwide survey in China. in Health expectations : an international journal of public participation in health care and health policy

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Munro, N Satisfaction with the health care system and trust in providers: a study in Chinese public opinion in Public Health Policy in Asia: Rights, Risks, Redistribution and Resilience, University of British Columbia, 6 & 7 December 2013

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Munro, N. Popular strategies for dealing with non-fiduciary prescribing: a policy-centred analysis in China's Health Reforms after Four Years: Public Evaluations,", Peking University, 16 September 2013

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Neil Munro And Ziying He Public Health Policy in Asia

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Sutton, Matt (2014) Impact of lack of trust in community clinics on hospital utilisation in China in International Health Economics Association/ECHE Congress

 
Description NEW DATA AND KNOWLEDGE
We conducted focus groups and then the first nationally representative survey of public attitudes toward the health care system in China, which generated a new publicly available dataset. The project resulted in new knowledge about Chinese people's trust, satisfaction and evaluations of providers' competence, convenience and ethical behaviour as well as their use of services. We held a workshop in Beijing, an academic conference and non-academic workshop in London, and produced and presented scholarly papers and briefings.

We found the Chinese public's trust in hospitals to be much higher than other researchers had expected. But we found trust in primary care providers to be low and strongly associated with higher hospital utilization, even for minor conditions such as headaches and colds. This strong association remained even when we controlled for income, insurance, convenience and other factors that have previously been found to influence utilization.

We found the Chinese population to be surprisingly satisfied with the health care system, and satisfaction to be strongly associated with having adequate health insurance and a belief in personal responsibility for meeting health care costs. Satisfaction was negatively associated with utilization of services, using social media for news, perceptions of access to services as unequal, and perceptions of service providers as unethical. This leads to the important policy implication that the Chinese government needs to improve the level of health insurance coverage (so that it better helps people meet their medical expenses), make access more equitable and reduce unethical behaviour by health care providers if it wishes to increase satisfaction.

While people say that the health care system and its reform is important to them, we did not find satisfaction with the health care system to be associated with support for the Chinese party-state.

NEW RESEARCH QUESTIONS OPENED UP
We measured trust asking a direct question and using this measure established a strong association between trust and health-seeking behaviour. More research is now needed to understand trust (and distrust) - in both primary care providers and hospitals. Distrust in clinics is not simply accounted for by evaluations of staff skills competence (as suggested by previous research that neglected trust) and further research is needed to understand it better.

We found the population to be more satisfied with the health care system than expected. Our cross-sectional survey was not able to fully establish the reasons for high levels of satisfaction that contrast with low evaluations of the system by health systems researchers. We have thus opened up questions about whether satisfaction tells us more about the trajectory of a health system than its absolute achievements. Further research might explore the effects of media reporting and of rapidly expanding social health insurance.

NEW NETWORKS AND COLLABORATIONS
There has been a great deal of interest in our findings from other researchers and invitations to present papers and collaborate on further analysis and possible research projects with colleagues in the State Council's Development Research Centre in Beijing, the Chinese Ministry of Human Resources and Social Security in China, the United Nations Research Institute for Social Development in Geneva and the Mercator Institute for Chinese Studies in Berlin.
Exploitation Route We hope that other health services researchers and social scientists will use our very rich survey database. Not only are we placing that database in the UK Research Service archive, we have developed an online tool, soon to be available on the project website, that enables researchers to do preliminary analyses using our data. We hope this will encourage researchers to use our full dataset.

We are also producing short briefing papers aimed at non-academic users who may be interested in our findings. These are linked to project publications and the project website.

Our findings on attitudes toward foreign health care providers and health insurance are of interest to UKTI and UK health sector (perhaps including pharmaceutical) businesses interested in investing in the Chinese health care market.

Our findings on evaluations, trust and satisfaction will be of interest to health systems researchers and they may wish to use our data for further analysis.

Our findings on people's values in relation to health care and their support for and trust in government will be of interest to a wide range or academic and non-academic users with an interest in contemporary Chinese society, government and justice.
Sectors Healthcare,Government, Democracy and Justice,Retail,Security and Diplomacy

URL http://www.gla.ac.uk/petu
 
Description Since our project concluded in August 2015 the investigators have continued to engage with potential users of our findings. We presented our survey data at a stakeholder conference in London in January 2015 and have followed up with research briefings based on the findings of our project that are prominently displayed on our project website. We have encountered a good deal of interest in our research, with participants in our stakeholder conference including representatives of UKTI, CBBC, and business people seeking to invest in China's health sector and benefit from China's health care market. Participants have said that our findings increased their understanding of China's health care system, the attitudes of its population (and potential as well as actual health care system users). As a result of our research we have been subsequently asked to speak at the China Investors' Club and have maintained exchanges with members of the UK business community working in China. While we cannot demonstrate any direct material effects of increased understanding, we hope that it will have helped both policy makers and business stakeholders to refine their market strategies and activities and thus benefit them going forward.
First Year Of Impact 2015
Sector Healthcare,Government, Democracy and Justice
Impact Types Economic,Policy & public services

 
Title China national health attitudes survey 2012-13 
Description  
Type Of Material Database/Collection of data 
Year Produced 2015 
Provided To Others? Yes  
 
Title PETU Survey 
Description The database is composed of the data collected in a nationally representative survey of the Chinese population conducted November 2012-January 2013. The survey asked standard socio-economic questions, as well as questions about people's satisfaction with the health system, evaluations of health service providers, trust in providers, health care values, recent utilization and health status. 
Type Of Material Database/Collection of data 
Provided To Others? No  
Impact We are currently analyzing data for our own publications and will release the database after the end of the project. 
 
Title Popular Views of the Chinese Health Care System 
Description  
Type Of Material Database/Collection of data 
Year Produced 2015 
Provided To Others? Yes  
 
Description Keynote address to a conference organized by the University of Chicago Centre in Beijing on the theme of "Violence Towards Health Care Professionals in China: an Assessment of Causes, Frequency, Prevention and Solutions." 17 September. 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact There was an interesting and sometimes passionate discussion about the causes and solutions of violence towards health care professionals in China.

A report quoting passages from his address appeared in Medical World, a Chinese language newspaper aimed at health care professionals.
Year(s) Of Engagement Activity 2013
URL http://www.uchicago.cn
 
Description Popular strategies for dealing with non-fiduciary prescribing: a policy-centred analysis, "China's Health Reforms after Four Years: Public Evaluations,", Peking University, 16 September 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact The workshop helped to publicize the results of the current research project amongst policy-makers and researchers in China.

Possibilities for future collaborative research were discussed.
Year(s) Of Engagement Activity 2013
URL http://www.gla.ac.uk/schools/socialpolitical/research/sccr/research/performanceevaluationstrustandut...
 
Description Project workshop organised in Beijing, China 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact 30 Chinese government health researchers and health policy advisers attended a project workshop that we organised in Beijing. The workshop's aim was to inform this audience of our project's key goals and findings, as well as to extend our network of academic and non-academic beneficiaries and users in China and create pathways for further impact in later stages of the project.

Researchers and advisers asked for more information about our project findings and outputs and expressed an interest in future collaboration. We anticipate that this will help us increase potential for impact later in the project.
Year(s) Of Engagement Activity 2013
 
Description User conference 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Industry/Business
Results and Impact 50 people from across industry/business and university sector attended a conference at which the project investigators made presentations aimed at a non-academic (industry/business) audience on the findings of our project. The presentations sparked many questions and lively discussion at the buffet lunch and networking session that followed. As a follow-up we were invited to speak at further events and to contribute to an industry publication.
Year(s) Of Engagement Activity 2015