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

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.

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.