Focus on vulnerable populations and promoting equity in health service utilization ––an analysis of visitor characteristics and service utilization of the Chinese community health service

In 1978, the Declaration of Alma-Ata formally adopted primary health care (PHC) by the World Health Organization (WHO) as the means for providing a comprehensive, universal, equitable, and affordable healthcare service for all countries [1]. Community health service (CHS) is the main form of PHC. Since the 1960s, many countries have attached importance to the organizational construction and the functional expansion of the CHS. For example, CHS facilities in England provide accessible primary care free of charge [2]. Beginning in the 1970s, Canada introduced community-oriented, multidisciplinary CHS, which focused on social justice and equity [3]. South Africa has implemented the policy of “Universal access to PHC for all South Africans” from 1994 and ever since, the community health institutions (CHIs) have contributed to improving the utilization of PHC [4].

In China, patients can usually choose the health service providers they prefer, and pay the chosen provider directly out-of-pocket. The competition stimulates the health service institutions to update facilities and equipment, enlarge scale, enroll excellent physicians by offering liberal salaries and benefits, and adopt a positive attitude towards patients’ preferences [5]. Consequently, superior health resources and patients concentrate at the secondary-tiered and third-tiered health service institutions, while there is a decline in the utilization of PHC institutions. This results in a serious equity problem, especially with regard to low-income patients who cannot afford high costs of health services. Health equity is the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically [6]. Achieving health equity usually involves ensuring that disadvantaged sectors of the population can both afford and gain access to relevant health services. Reducing health inequities is, for the WHO Commission on Social Determinants of Health, an urgent and ethical imperative [7]. In 1997, the Chinese government endeavored to develop a convenient and affordable primary health service -CHS -for the city residents to meet the PHC need of all populations, especially vulnerable populations who experience limited resources and consequent high relative risk of morbidity and premature mortality [8], and to promote health equity.

Chinese CHIs are divided into two levels: health centers and health stations. A health center covers 30,000 to 50,000 residents and can be equipped with inpatient beds, while a station covers about 3,000 residents and isn’t equipped with inpatient beds [5]. Both health centers and health stations provide outpatient service and emergency service. Patients can seek medical services (including diagnosis and treatment, purchasing medicines, and rehabilitation) and public health services (including health check, preventive care, and health education) in CHIs. By the end of 2010, 98% of cities in mainland China have established CHS systems, including 6,903 centers and 25,836 stations in total [9].

For the 21st century, equity in health service utilization remains a major concern, as an important aspect of the health equity. With the rapid development of the Chinese CHS [5, 10, 11], a more policy relevant question is whether the CHS system in China is doing what it’s designed to do, what’s the effect of CHS system on meeting the PHC need of vulnerable populations, or further what’s the role of CHS system in promoting equity in health service utilization. There is a lack of studies on this issue [12‐14]. Thus, we conducted a four-year continuous investigation on the visitors of CHIs with a large sampling size at the national level. By analyzing the visitors’ demographic characteristics, and comparing that with 2008 National Health Services Survey (NHSS) in Chinese cities [15], we aimed to assess whether CHIs attracted vulnerable populations to seek for health services. The NHSS was a sampling survey of visitors of all levels of health institutions nationwide (including CHIs). We also analyzed the service types used by different visitors (especially the vulnerable populations) and their satisfactions. The purposes were to investigate what types of services they were likely to use and whether they were satisfied, and then to grasp what aspects of the services should be improved to better serve the patients.

The present study showed that the proportion of female visitors of Chinese CHIs was 55.3% – 57.4%, close to 55.3% reported by NHSS. Similar proportions were reported in other counties such as UK (64.1%) [21], Canada (65.0%) [3], Australia (51.8%) [22], United Arab Emirates (57.0%) [23] and South Africa (66.6%) [24].

The proportion of children in CHI visitors was apparently lower than that of NHSS. A study elsewhere has suggested that the training of doctors for child health care was limited in CHIs [25]. Nowadays, most Chinese families have only one child. Parents attach great importance to their child’s health, and are more likely to seek health care in higher level hospitals when their children get sick [26]. Furthermore, our study indicated that the overall satisfaction of the children group was the lowest. As to the elderly, the proportion was also lower than that of the NHSS. This may be because old patients are more likely to have chronic diseases requiring hospitalization [15], but most CHIs in China do not provide hospitalization service, and then many elderly patients bypass CHIs to go to higher level hospitals for inpatient care service. Moreover, a study elsewhere has found that less than 40% of the chronic patients had been managed in community in China [27], which leads to a large number of chronic patients receiving specialty services in large hospitals rather than in CHIs.

The proportion of CHI visitors with low-income was significantly higher than that reported by NHSS, which indicated that low-income patients tended to use CHS. This may be associated with the payment of service costs. In Canada, patients with lower incomes are less likely to visit specialists than those with moderate or high incomes, after adjusting for self-perceived health status and health problems [28]. In China, the medical insurances mainly cover hospitalization and critical illnesses, the reimbursement rates of which reach 75%, while the reimbursement rate of outpatient costs is only 23% [29]. As a result, the patients still have to pay a larger proportion of outpatient costs. The main objective of Chinese CHIs is to satisfy the basic health service needs of populations, and the outpatient cost in CHIs is substantially lower than that in higher level hospitals. Thus, given the low price, low-income patients are more likely to go to CHIs for outpatient service. In addition, this study showed that the low-income group had higher satisfaction with the CHS. However, both expenditure and service qualities are important. The skill level of the physicians in CHIs is still lower than in higher level hospitals nowadays. Therefore, most patients with high-income may continue to bypass CHIs for perceived higher quality specialist care in high level hospitals [30, 31].

The poor, as a vulnerable population according to the international standards, are among the target populations of the Chinese CHS [32]. One of the purposes of developing CHS is to alleviate the problem of low consultation rate of patients, especially vulnerable populations. This study indicated that the low-income patients were more likely to use CHIs for health services, which suggest that developing CHS may attract low-income patients to seek health care, and consequently promote the equity in health service utilization. However, our results also reflect that the Chinese CHIs should strengthen the services for children and the elderly.

The quality of CHS and whether it could meet the demands of patients should be evaluated ultimately by users of the CHIs. The present study found that the visitor satisfactions about CHI services are above 90% in terms of service convenience, providers’ attitude, respect to patients, and avoidance of excessive examinations or over-prescription. However, the level of satisfaction of CHI visitors was only about 75% regarding medical equipment and drug prices. Therefore, equipment of the Chinese CHIs should be much improved in order to meet visitors’ needs. Studies suggested that by way of increasing government investment, improving the compensation mechanisms and medical insurance system, drug prices could be decreased effectively [33, 34]. As to avoidance of excessive examinations or over-prescription, care should be taken in the interpretation of the satisfaction values, because the views of health care providers were not taken into account in this investigation.

The overall satisfactions were the lowest among children visitors (81.2%) and the highest in the elderly (91.2%). However, there were no practically meaningful differences in overall satisfaction between females and males, and between low-income and higher-income visitors.

There were small differences in types of health services used in CHIs between visitor groups in terms of gender and income. As to different ages, the utilization rate of preventive care was higher for children, at least partly due to free vaccinations of children in CHIs. Elderly visitors were more likely to use services of purchasing medicine, health check, and health education.

The Chinese government emphasizes the balanced development of basic medical services and public health services provided in CHIs. Nevertheless, the utilization of certain public health services was still insufficient by 2011. The utilization rate of preventive care services was only 9.0%, which was far less than New Zealand (18.9%), Poland (29.1%), America (25.7%), and some other countries [35‐37]. This may be attributed to a lack of sufficient appreciation of the importance of the disease prevention in the community [38], or that public health services have not been fully implemented in CHIs. In England, in order to motivate general practitioners to do well in prevention work, general practitioners’ incomes are varied according to the quality and performance of public health services they provide [39]. In Germany, some preventive care services have been covered by medical insurance. In addition, a study suggested that the attitudes towards disease prevention in the community should be changed by health education [40]. China could take similar approaches to improve the utilization of the public health services.

A large proportion of low-income group used CHIs for health care services, and CHIs may play an important role in promoting equity in health service utilization. However, the proportions of children and elderly visitors who used CHIs were still low, and services for children and the elderly should be strengthened. Satisfactions of various visitor groups were high in terms of service convenience, providers’ attitude, respect to patients and avoidance of excessive examinations or over-prescription. However, visitors in CHIs had lower satisfactions in terms of medical equipment and drug prices. The children had the lowest overall satisfactions than other age groups. The use of public health services provided by CHIs was still generally insufficient.