Essential books for health workers in the Third World.

Some of the issues relating to access to medical reference information in developing countries is delineated: the selection of core collections, title selection, funding, and accommodation, supervision, and use of collections. Provision of medical textbooks has been ignored in the movement after Alma Ata to strengthen primary health care. Now that the infrastructures are partially in place there is need to improve the availability of medical information. In developing countries, information and communication systems outside cities are problematic. Library extension services in rural areas are limited and the needs are case related. Health care facilities need carefully selected textbooks and manuals: core collections. The experiences in Zimbabwe resulted in the selection of several core lists: 40 references and manuals for hospitals, and 13 textbooks for health center staff. There are economic constraints when a standard European or American medical textbook costs $85 and a nursing textbook $45 and the need, as in the case of Zimbabwe, requires collections for 1000 health care facilities. The source of supply in Zimbabwe and Malawi was the British Council's Educational Law-price Book Scheme, "Teaching Aids at Low Cost." Rural health manuals were available at low cost from the African Medical and Research Foundation. WHO also provides core materials on suitable topics at low prices and availability in several major languages. Other factors besides cost in the selection involve appropriateness to local disease patterns, geographical and environmental characteristics, and the composition and level of the health community. Journals should be included. In Zimbabwe a joint effort was made for core selection by Ministry of Health senior members in the Division of Health Manpower Development and Health Education, 3 medical librarians, a faculty members of the University of Zimbabwe, and advice from several district hospital physicians In Malawi, selection was made by the Ministry of Health and then distributed for comment. Government requires help in funding. Space needs to made available for free accessibility of materials. A staff member should be in charge of the use and intactness of the collection but staff should satisfy their own needs. Rural staff may need to be educated on the importance of use of reference materials.     

Economic contribution of gynecological and obstetrical ultrasound in an advanced strategy for the Zinguinchor region

Aiming to strengthen the accessibility of ultrasound technology to rural populations, an advanced strategy ultrasound programme was implemented in the health districts of Sedhiou, Oussouye, Bignona and Ziguinchor all located within Casamance in Senegal. Within the first year of activity (January 1, 2001-December 31, 2001), the team from the regional health centre (RHC) was dispatched 56 times. Ultrasound scans were performed in the homes of 1,273 patients among which 192 were referred to the RHC for specialised follow-up and treatment. The financial benefit for the RHC totaled 3,120,000 francs; 2,612,500 francs for the district hospital; and 3,561,300 francs for the population at large. The advanced strategy for performing ultrasound scans has therefore been economically profitable at the community level as much as at the level of health structures. Through supporting the activities of the district hospitals, the RHC contributed technical support and increased the potential, not solely for the treatment of disease but for the health services overall. The revenue generated has given managers a greater possibility to improve health care and services. The decentralisation programme and reduction in the cost have decreased the unsatisfied needs in ultrasound services by making the technology more financially and geographically accessible. Thus, by saving input costs in terms of time, transportation and capital, the practice of ultrasound scans in district hospitals has been strengthened and has improved the capacity to provide care and treat the population's health problems. The continuation of this programme is advantageous, but necessitates two complementary actions: enhancing of the technical level and capacity of the district hospitals with the installation of ultrasound technology and equipment, and raising the level of knowledge by training staff in administering ultrasound scans.     

Costing of services of Vietnamese hospitals: identifying costs in one central, two provincial and two district hospitals using a standard methodology

BACKGROUND: The People's Republic of Vietnam is currently in a period of transition from a purely socialistic country towards a so-called socialist market economy. Since the introduction of the Doi Moi policy in 1987, health care services have been liberalized, medical practitioners have received the right to open private hospitals and private pharmacies are booming. However, the majority of inhabitants strongly depends on governmental hospital services. These services are currently going through a financial crisis. This demands the quest for efficiency and the wise allocation of public funds. RESEARCH QUESTION: The efficient allocation of funds depends on the quotient between costs and health outcomes, but the costs of health services in Vietnamese hospitals are unknown. Therefore the study analysed five hospitals in Vietnam and determined the average costs as well as the main cost drivers. METHODOLOGY: The full costs of five hospitals were analysed, including depreciation and the value of donations. The costs were allocated to cost centres and cost units by a stepping-stone method. MAJOR FINDINGS: As expected, the average costs per inpatient day at a central hospital are about 300% of the costs of provincial hospitals and about 600% of the costs of district hospitals. However, the costs of some laboratory procedures and operations done at district hospitals are higher than those of provincial or even central hospitals. The main reason for the high costs of some procedures at district hospitals was the low quantity of these procedures at that level. This is a strong indicator that some procedures, in particular major operations, should not be performed in Vietnamese district hospitals.     

Zimbabwe's hospital referral system: does it work?

BACKGROUND: Anecdotal evidence has suggested inefficiency in the pyramidal health care referral system established in Zimbabwe in 1980, as part of its primary health care (PHC) model. AIM: To assess the functioning of the pyramidal referral system in two rural districts surrounding Harare, Zimbabwe, with regard to two common indicator conditions: pneumonia in children and malaria in adults. METHODS: For a three-month period, all complete inpatient records with discharge diagnoses of pneumonia or malaria from three hospitals representing different levels of care were analyzed (n = 227). Data were collected on demographic and patient care variables. The appropriateness of admissions and referrals was determined by an assessment of the severity of illness and 'intensiveness' of care required. Data were analyzed for differences among the three hospitals and between the two indicator conditions. Per night inpatient bed costs for each hospital were also calculated. RESULTS: For pneumonia in children, 56.8% of patients admitted at the secondary level, 53.8% of patients at the tertiary level and 57.8% of patients at the quaternary level were of mild severity. For malaria in adults, 74.0% of patients seen at the secondary level, 81.5% of patients at the tertiary level and 54.3% at the quaternary level were of mild severity. For pneumonia, were no differences in severity between the three hospitals whereas for malaria significant case-mix differences among the hospitals were found. Most patients attending the highest level referral facility were inappropriate admissions who could have been treated at a lower level of care. The majority of patients at all the hospitals studied had used that hospital as their first or second point of contact with the health services. There were large variations in the inpatient per night bed costs between the three hospitals. CONCLUSIONS: Using the indicator diseases of pneumonia in children and malaria in adults, this study concluded that this network did not meet design expectations as the central level referral hospital cared for a similar case-mix of patients as the district level, but at six times the cost. The appropriateness of admissions and referrals could be improved by developing or strengthening intermediate level facilities, by changing mechanisms of access to specialist facilities and by training health professionals in community settings.     

Costing of clinical services in rural district hospitals in northern Vietnam

Objectives: This study aimed to estimate and analyse the “actual” unit cost of providing key clinical services in selected rural district hospitals in the North of Vietnam. It also examined the relationship between actual costs and the levels of cost covered by the corresponding user fees paid by patients. Methods: This was a facility‐based costing study which estimates the costs of health care services from the perspective of the service providers. Three rural district hospitals from three provinces in the North of Vietnam were purposively selected for this study. The “step‐down” approach was applied. Results: There was little difference in the costs of an outpatient visit across the hospitals, but the costs of an operation and an inpatient day varied considerably. In terms of cost structure, personnel costs accounted for the highest share of total cost of the clinical services. The shares of operating cost were considerable while depreciation of buildings/equipments made up a small “proportion”. The study results revealed that the user fee levels were much lower than the actual costs of providing the corresponding services. The present study highlights the importance of costing data for hospital planning and management. Copyright © 2009 John Wiley & Sons, Ltd.     

The fall and rise of cost sharing in Kenya: the impact of phased implementation

The combined effects of increasing demand for health services and declining real public resources have recently led many governments in the developing world to explore various health financing alternatives. Faced with a significant decline during the 1980s in its real per capita expenditures, the Kenya Ministry of Health (MOH) introduced a new cost sharing programme in December 1989. The programme was part of a comprehensive health financing strategy which also included social insurance, efficiency measures, and private sector development. Early implementation problems led to the suspension in September 1990 of the outpatient registration fee, the major revenue source at the time. In 1991, the Ministry initiated a programme of management improvement and gradual re-introduction of an outpatient fee, but this time as a treatment fee. The new programme was carried out in phases, beginning at the national and provincial levels and proceeding to the local level. The impact of these changes was assessed with national revenue collection reports, quality of care surveys in 6 purposively selected indicator districts, and time series analysis of monthly utilization in these same districts. In contrast to the significant fall in revenue experienced over the period of the initial programme, the later management improvements and fee adjustments resulted in steady increases in revenue. As a percentage of total non-staff expenditures, fiscal year 1993-1994 revenue is estimated to have been 37% at provincial general hospitals, 20% at smaller hospitals, and 21% at health centres. Roughly one third of total revenue is derived from national insurance claims. Quality of care measures, though in some respects improved with cost sharing, were in general somewhat mixed and inconsistent. The 1989 outpatient registration fee led to an average reduction in utilization of 27% at provincial hospitals, 45% at district hospitals, and 33% at health centres. In contrast, phased introduction of the outpatient treatment fee beginning in 1992, combined with somewhat broader exemptions, was associated with much smaller decreases in outpatient utilization. It is suggested that implementing user fees in phases by level of health facility is important to gain patient acceptance, to develop the requisite management systems, and to orient ministry staff to the new systems.     

Global budgets in Maryland: early evidence on revenues,expenses, and margins in regulated and unregulated services

Maryland implemented one of the most aggressive payment innovations the nation has seen in several decades when it introduced global budgets in all its acute care hospitals in 2014. Prior to this, a pilot program, total patient revenue (TPR), was established for 8 rural hospitals in 2010. Using financial hospital report data from the Health Services Cost Review Commission from 2007 to 2013, we examined the hospitals’ financial results including revenue, costs, and profit/loss margins to explore the impact of the adoption of the TPR pilot global budget program relative to the remaining hospitals in the state. We analyze financial results for both regulated (included in the global budget and subject to rate-setting) and unregulated services in order to capture a holistic image of the hospitals’ actual revenue, cost and margin structures. Common size and difference-in-differences analyses of the data suggest that regulated profit ratios for treatment hospitals increased (from 5% in 2007 to 8% in 2013) and regulated expense-to-gross patient revenue ratios decreased (75% in 2007 and 68% in 2013) relative to the controls. Simultaneously, the profit margins for treatment hospitals’ unregulated services decreased (??12% in 2007 and ??17% in 2013), which reduced the overall margin significantly. This analysis therefore indicates cost shifting and less profit gain from the program than identified by solely focusing on the regulated margins.     

A systematic review of different models of home and community care services for older persons

Background

The Government of the Republic of Kenya is in the process of implementing health care reforms. However, poor knowledge about costs of health care services is perceived as a major obstacle towards evidence-based, effective and efficient health care reforms. Against this background, the Ministry of Health of Kenya in cooperation with its development partners conducted a comprehensive costing exercise and subsequently developed the Kenya Health Sector Costing Model in order to fill this data gap.

Methods

Based on standard methodology of costing of health care services in developing countries, standard questionnaires and analyses were employed in 207 health care facilities representing different trustees (e.g. Government, Faith Based/Nongovernmental, private-for-profit organisations), levels of care and regions (urban, rural). In addition, a total of 1369 patients were randomly selected and asked about their demand-sided costs. A standard step-down costing methodology was applied to calculate the costs per service unit and per diagnosis of the financial year 2006/2007.

Results

The total costs of essential health care services in Kenya were calculated as 690 million Euros or 18.65 Euro per capita. 54% were incurred by public sector facilities, 17% by Faith Based and other Nongovernmental facilities and 23% in the private sector. Some 6% of the total cost is due to the overall administration provided directly by the Ministry and its decentralised organs. Around 37% of this cost is absorbed by salaries and 22% by drugs and medical supplies. Generally, costs of lower levels of care are lower than of higher levels, but health centres are an exemption. They have higher costs per service unit than district hospitals.

Conclusions

The results of this study signify that the costs of health care services are quite high compared with the Kenyan domestic product, but a major share are fixed costs so that an increasing coverage does not necessarily increase the health care costs proportionally. Instead, productivity will rise in particular in under-utilized private health care institutions. The results of this study also show that private-for-profit health care facilities are not only the luxurious providers catering exclusively for the rich but also play an important role in the service provision for the poorer population. The study findings also demonstrated a high degree of cost variability across private providers, suggesting differences in quality and efficiencies.     

Expanding access to primary care without additional budgets? A case study from Burkina Faso

The aim of this study is to demonstrate the impact of increased access to primary care on provider costs in the rural health district of Nouna, Burkina Faso. This study question is crucial for health care planning in this district, as other research work shows that the population has a higher need for health care services. From a public health perspective, an increase of utilisation of first-line health facilities would be necessary. However, the governmental budget that is needed to finance improved access was not known. The study is based on data of 2004 of a comprehensive provider cost information system. This database provides us with the actual costs of each primary health care facility (Centre de Santé et de Promotion Sociale, CSPS) in the health district. We determine the fixed and variable costs of each institution and calculate the average cost per service unit rendered in 2004. Based on the cost structure of each CSPS, we calculate the total costs if the demand for health care services increased. We conclude that the total provider costs of primary care (and therefore the governmental budget) would hardly rise if the coverage of the population were increased. This is mainly due to the fact that the highest variable costs are drugs, which are fully paid for by the customers (Bamako Initiative). The majority of other costs are fixed. Consequently, health care reforms that improve access to health care institutions must not fear dramatically increasing the costs of health care services. This study was supported by a research grant of the German Research Foundation (Deutsche Forschungsgemeinschaft).     

Economic Effects of the Outmigration of Obstetric Services in a Rural County

Obstetrical health care resources have been declining in rural areas since 1980, resulting in reduced prenatal care that can result in higher medical costs. Loss of health care services is known to have negative economic consequences for rural communities. This article illustrates how hospitals and other providers of medical services can be used as vehicles for local economic development. Provision of medical services is an important component of the economic base of all communities and especially of small rural communities with hospitals. When a community loses medical services to another community, it loses both direct and indirect economic benefits. The research presented here analyzes the economic effects of outmigration of obstetric services from a rural "perimeter" community in Wyoming. The combined direct and indirect economic losses are shown to be significant. Annual revenue losses to the local hospital were estimated as high as 12 percent. It is important to make explicit the economic losses that result from reductions in health care. Such research, combined with knowledge of negative health and social factors can provide community leaders with additional motivation to find solutions to declining health care in rural areas.     

A Rural Cancer Outreach Program Lowers Patient Care Costs and Benefits Both the Rural Hospitals and Sponsoring Academic Medical Center

The Rural Cancer Outreach Program (RCOP) between two rural hospitals and the Medical College of Virginia's Massey Cancer Center (MCC) was developed to bring state-of-the-art cancer care to medically underserved rural patients. The financial impact of the RCOP on both the rural hospitals and the MCC was analyzed. Pre- and post-RCOP financial data were collected on 1,745 cancer patients treated at the participating centers, two rural community hospitals and the MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins and profit (or loss) of the program. The RCOP may have enhanced access to cancer care for rural patients at less cost to society. The net annual cost per patient fell from $10,233 to $3,862 associated with more use of outpatient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to the Medical College of Virginia fell by more than 40 percent compared with only an 8 percent decrease for all other cancer patients. The rural hospitals experienced rapid growth of their programs to more than 200 new patients yearly, and the RCOP generated significant profits for them. MCC benefited from increased referrals from RCOP service areas by 330 percent for cancer patients and by 9 percent for non-cancer patients during the same time period. While it did not generate a major profit for the MCC, the RCOP generated enough revenue to cover costs of the program. The RCOP had a positive financial impact on the rural and academic medical center hospitals, provided state-of-the-art care near home for rural patients and was associated with lower overall cancer treatment costs.     

Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe

Unless strategies are found to galvanise rural communities and create a demand for sanitation, we cannot achieve the United Nations Millennium Development Goal of halving the 2.4 billion people without sanitation by the year 2015. This study describes an innovative methodology used in Zimbabwe--Community Health Clubs--which significantly changed hygiene behaviour and built rural demand for sanitation. In 1 year in Makoni District, 1244 health promotion sessions were held by 14 trainers, costing an average of US dollars 0.21 per beneficiary and involving 11,450 club members (68,700 beneficiaries). In Tsholotsho District, 2105 members participated in 182 sessions held by three trainers which cost US dollars 0.55 for each of the 12,630 beneficiaries. Within 2 years, 2400 latrines had been built in Makoni, and in Tsholotsho latrine coverage rose to 43% contrasted to 2% in the control area, with 1200 latrines being built in 18 months. Although Zimbabwe has historically relied on subsidies to stimulate sanitation, this intervention shows how total sanitation could be achievable. The remaining 57% of club members without latrines in Tsholotsho all practised faecal burial, a method previously unknown to them. Club members' hygiene was significantly different (p<0.0001) from a control group across 17 key hygiene practices including hand washing, showing that if a strong community structure is developed and the norms of a community are altered, sanitation and hygiene behaviour are likely to improve. This methodology could be scaled up to contribute to ambitious global targets.     

The costs of public primary health care services in rural Indonesia

Described are the results of a cost study of national rural health services carried out in Indonesia between November 1986 and March 1987. Detailed costings of government inputs to all public health services below the district hospital level were made for 41 subdistricts in five provinces that were representative of the different regions of the country. The total costs of services as well as the average costs for specific service functions were estimated for the whole country as well as for the different provinces. The results indicate a low overall level of government spending on rural primary health care. Regional differences in this respect were not significant, suggesting that the government policy of encouraging regional balance in allocations has been successful. The average costs for most services were much greater than the charges made to patients, and this provided information on the current level of government subsidies. There was a large variability in the average costs, indicating that the existing system is inefficient, that some districts were able to attain much higher levels of efficiency than others within the existing constraints, and that improvements in this respect are possible.     

The challenge of measuring quality of care at health centre level in Africa: the example of Tsholotsho health district in Matabeleland North, Zimbabwe

This study is on the evaluation of quality of health care within first line health services in rural Zimbabwe. It took place between 2001 and 2002, and consisted of a cross-sectional survey designed to compare the quality of health care on offer at a newly created health centre with that provided by the district hospital's outpatient department. The hypothesis to be tested was that the health centre offered better quality of care. A comprehensive quality of care evaluation framework was designed. The concept of patient enablement was incorporated into the study's assessment of health care delivery outcomes. The results did not provide conclusive evidence that the care offered at the health centre was better than the care on offer at the hospital OPD. The reasons for these unexpected findings are discussed in depth. They are related to the limited understanding amongst local health workers of the organisational changes introduced by the District Health Executive (DHE), together with a (European) cultural bias in the quality of care model under test. An important lesson of this study is that the notion of enablement, notwithstanding the need to put into context the tools used to measure it, was considered by the DHE as relevant in the organisation and evaluation of health care.     

Socio-economic status and health care utilization in rural Zimbabwe: findings from Project Accept (HPTN 043)

Zimbabwe's HIV epidemic is amongst the worst in the world, and disproportionately effects poorer rural areas. Access to almost all health services in Zimbabwe includes some form of cost to the client. In recent years, the socio-economic and employment status of many Zimbabweans has suffered a serious decline, creating additional barriers to HIV treatment and care. We aimed to assess the impact of i) socio-economic status (SES) and ii) employment status on the utilization of health services in rural Zimbabwe. Data were collected from a random probability sample household survey conducted in the Mutoko district of north-western Zimbabwe in 2005. We selected variables that described the economic status of the respondent, including: being paid to work, employment status, and SES by assets. Respondents were also asked about where they most often utilized healthcare when they or their family was sick or hurt. Of 2,874 respondents, all forms of healthcare tended to be utilized by those of high or medium-high SES (65%), including private (65%), church-based (61%), traditional (67%), and other providers (66%) (P=0.009). Most respondents of low SES utilized government providers (74%) (P=0.009). Seventy-one percent of respondents utilizing health services were employed. Government (71%), private (72%), church (71%), community-based (78%) and other (64%) health services tended to be utilized by employed respondents (P=0.000). Only traditional health services were equally utilized by unemployed respondents (50%) (P=0.000). A wide range of health providers are utilized in rural Zimbabwe. Utilization is strongly associated with SES and employment status, particularly for services with user fees, which may act as a barrier to HIV treatment and care access. Efforts to improve access in low-SES, high HIV-prevalence settings may benefit from the subsidization of the health care payment system, efforts to improve SES levels, political reform, and the involvement of traditional providers.     

Willingness to pay for district hospital services in rural Tanzania

This paper describes a study undertaken to investigate the willingness of patients and households to pay for rural district hospital services in north-western Tanzania. The surveys undertaken included interviews with 500 outpatients and 293 inpatients at three district level hospitals, interviews with 1500 households and discussions with 22 focus groups within the catchment areas of the primary health care programmes of these hospitals. Information was collected on willingness to pay fees for certain hospital services, willingness to become a member of a local insurance system, and exemptions for cost-sharing. The willingness to pay for district hospital services was large. Furthermore, most respondents favoured a local insurance system above user fee systems, a finding which applied at all places and in all the surveys. More female respondents were in favour of a local insurance scheme. The conditions needed for the introduction of a local insurance system are discussed.     

The impact of the introduction of user fees at a district hospital in Cambodia

Proponents of user fees in the health sector in poor countries cite a number of often interrelated rationales, relating inter alia to cost recovery, improved equity and greater efficiency. Opponents argue that dramatic and sustained decreases in service utilization follow the introduction of user fees, highlighting evidence that user fees reduce service utilization when they fail to result in improved quality of care and/or when services are priced higher than those charged by private health care providers. Utilization of public health services in Cambodia is low. Supply-side factors are significant determinants of such low public sector utilization, including low official salaries of service providers (forcing many to seek additional income in the private sector), and operations budgets which are erratic and often insufficient to cover running costs of service delivery outlets. The Cambodia Ministry of Health (MOH) encourages user fee schemes at operational district level. By allowing revenue to be retained at the health facility level, the MOH aims to improve health care delivery--and consequently service utilization--through increased salaries to health facility staff and increases in operations budgets. This case study of the introduction of user fees at a district referral hospital in Kirivong Operational District in Cambodia, using the findings from empirical research, examines the impact of user fees on health-careseeking behaviour, ability to pay and consultation prices at private practitioners. The research showed that consultation fees charged by private providers increased in tandem with price increases introduced at the referral hospital. It further demonstrates--for the first time that we are aware of from the available literature--that the introduction and subsequent increase in user fees created a 'medical poverty trap', which has significant health and livelihood impact (including untreated morbidity and long-term impoverishment). Addressing the medical poverty trap will require two interventions to be implemented immediately: regulation of the private sector, and reimbursing health facilities for services provided to patients who are exempted from paying user fees because of poverty. A third, longer-term initiative is also suggested: the establishment of a social health insurance mechanism.     

Costing maternal health services in South Tanzania

The following paper presents the methodology and results of a costing exercise of maternal health services in Tanzania. The main objective of this study was to determine the actual costs of antenatal and obstetric care in different health institutions in a district in Tanzania as a basis of more efficient resource allocation. A costing tool was developed that allows the calculation of costs of service units, such as deliveries and antenatal care, and separates these costs from the costs of other services. Time consumed by each activity was used as an allocation key. For that purpose, we recorded the personnel consumption with different time-study methodologies. This approach was tested and implemented in Mtwara Urban District, South Tanzania. The results were analyzed by a spreadsheet program. The paper presents average costs for different costing units of maternal care. Among other findings, we found that the cost of a normal vaginal delivery is US $12.30 in a dispensary and US $6.30 in the hospital—a result that needs explanation, as usually one would expect that hospitals are more cost-intensive than first-line facilities. However, dispensaries are grossly underutilized so that the costs per service unit are rather high. The cost for surgical delivery (only in hospitals) was found to be US $69.26 and the average cost per antenatal care consultation (only at dispensaries) was US $2.50. We conclude that improved planning of elective services is a prerequisite for more effective and efficient use of personnel resources. In addition, the definition of medically and economically sound standards, in particular staffing standards, is critical to make cost analysis an effective management tool to guide rational resource allocation.     

How Does Degree of Rurality Impact the Provision of Surgical Services at Rural Hospitals?

ABSTRACT:  Context: Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. Purpose: To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. Methods: A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. Findings: One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. Conclusions: Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.     

Rural–urban disparities in the utilization of mental health inpatient services in China: the role of health insurance

Reducing rural–urban disparities in health and health care has been a key policy goal for the Chinese government. With mental health becoming an increasingly significant public health issue in China, empirical evidence of disparities in the use of mental health services can guide steps to reduce them. We conducted this study to inform China’s on-going health-care reform through examining how health insurance might reduce rural–urban disparities in the utilization of mental health inpatient services in China. This retrospective study used 10 years (2005–2014) of hospital electronic health records from the Shandong Center for Mental Health and the DaiZhuang Psychiatric Hospital, two major psychiatric hospitals in Shandong Province. Health insurance was measured using types of health insurance and the actual reimbursement ratio (RR). Utilization of mental health inpatient services was measured by hospitalization cost, length of stay (LOS), and frequency of hospitalization. We examined rural–urban disparities in the use of mental health services, as well as the role of health insurance in reducing such disparities. Hospitalization costs, LOS, and frequency of hospitalization were all found to be lower among rural than among urban inpatients. Having health insurance and benefiting from a relatively high RR were found to be significantly associated with a greater utilization of inpatient services, among both urban and rural residents. In addition, an increase in the RR was found to be significantly associated with an increase in the use of mental health services among rural patients. Consistent with the existing literature, our study suggests that increasing insurance schemes’ reimbursement levels could lead to substantial increases in the use of mental health inpatient services among rural patients, and a reduction in rural–urban disparities in service utilization. In order to promote mental health care and reduce rural–urban disparities in its utilization in China, improving rural health insurance coverage (e.g., reducing the coinsurance rate) would be a powerful policy instrument.