With a goal of improving health system quality and efficiency, reforms of China's health system over the past decade have sought to strengthen primary healthcare in lower-level clinics and health centers. Despite these wide-ranging reforms and initiatives, population-based studies have documented dramatic declines in patients' use of primary care facilities during this period. In this paper, we explore the determinants of this trend in China's rural areas using detailed longitudinal data following a nationally-representative sample of rural households and village clinics from 2011 to 2018. We estimate that between 2011 and 2018, the probability that individuals sought care at village clinics when ill dropped by 44%. At the same time, the utilization of outpatient services in county hospitals increased by 56% and patient self-treatment increased by 20%. Detailed Kitagawa-Oaxaca-Blinder decompositions suggest four primary drivers of this trend: the shifting burden of disease in rural areas, changes in how patients choose to seek care given different disease conditions, declining drug inventory in village clinics, and the decreasing importance of remoteness as a determinant of healthcare seeking behavior. Our results highlight the deteriorating role of village clinics in the rural healthcare system and the increasing importance of self-treatment and higher-tier primary care services.

Poor knowledge, scarce resources, and lack of or misaligned incentives have been widely documented as drivers of the irrational use of medicine (IUM), which significantly challenges the efficiency of health systems across the globe. However, there is limited understanding of the influence of each factor on IUM. We used detailed data on provider treatment of presumptive asthma cases in rural China to assess the contributions of provider knowledge, resource constraints, and provider behavior on IUM. This study enrolled 370 village providers from southwest China. All providers responded to a clinical vignette to test their knowledge of how to treat presumptive asthma. Resource constraints (“capacity”) were defined as the availability of the prescribed medicines in vignette. To measure provider behavior (“performance”), a subset of providers (104 of 370) were randomly selected to receive unannounced visits by standardized patients (SPs) who performed of presumptive asthma symptoms described in the vignette. We found that, 54% (201/370) of providers provided the vignette-based patients with prescriptions. Moreover, 67% (70/104) provided prescriptions for the SPs. For the vignette, only 10% of the providers prescribed the correct medicines; 38% prescribed only unnecessary medicines (and did not provide correct medicine); 65% prescribed antibiotics (although antibiotics were not required); and 55% prescribed polypharmacy prescriptions (that is, they prescribed five or more different types of drugs). For the SP visits, the numbers were 12%, 51%, 63%, and 0%, respectively. The lower number of medicines in the SP visits was due, in part, to the injections’ not being allowed based on ethical considerations (in response to the vignette, however, 65% of providers prescribed injections). The difference between provider knowledge and capacity is insignificant, while a significant large gap exists between provider performance and knowledge/capacity (for 11 of 17 indicators). Our analysis indicated that capacity constraints play a minor role in driving IUM compared to provider performance in the treatment of asthma cases in rural China. If similar findings hold for other disease cases, this suggests that policies to reduce the IUM in rural China have largely been unsuccessful, and alternatives for improving aligning provider incentives with appropriate drug use should be explored.

Background Although the progress in global health initiatives has improved the availability of primary health care (PHC), unqualified healthcare remains a serious challenge in low- and middle-income countries, where PHC is often underutilized. This study examines factors associated with patients’ healthcare-seeking behaviors in rural Chin—seeking healthcare at village-level PHC providers, at higher-level health facilities, self-medicating, and refraining from seeking medical help. We focus on provider-side factors, including (1) the unobservable quality indicator, (2) the observable quality indicator, and (3) the observable signal indicator. Methods We analyzed 1578 episodes of healthcare-seeking behaviors of patients with diarrhea or cough/runny nose symptom from surveys conducted in July 2017 and January 2018 in 114 villages of the Yunnan province. We investigated the correlation between quality-related factors with patients’ healthcare-seeking behaviors by multinomial logit regression. Results We found that rural patients were insensitive to the unobservable quality of healthcare providers, as measured by standardized clinical vignettes, which might be attributable to the credence nature of PHC. The observable quality indicator, whether the clinician has received full-time junior college formal medical education, was associated with patients’ healthcare choices. Patients, however, were more likely to select healthcare based on the observable signal indicator, which was measured by the availability of medicines. Additionally, the observable signal indicator had no significant association with two quality indicators. Notably, socioeconomically-disadvantaged patients relied more on the village-level PHC, which emphasized the role of PHC in promoting the welfare of rural populations. Conclusions Our study found an inconsistency between objective quality of healthcare provided by providers and subjective quality perceived by patients. Patients could not identify the actual quality of PHC precisely, while they were more likely to make decisions based on the observable signal indicator. Therefore, the quality of PHC should be more observable to patients. This study not only supplements the literature on healthcare-seeking choices by examining four types of behaviors simultaneously but also clarifies rural patients’ perceptions of the quality of PHC for policy decision-making on increasing the utilization of PHC and improving the medical welfare of the vulnerable.

Background Non-physician clinicians (NPCs) providing services in functionally private markets account for a large share of the workforce in the primary care system in many low-income and middle-income countries. Although regular in-service training is believed to be crucial to updating NPCs’ professional knowledge, skills, and practices, participation rates are often low. Low participation may result from the “credence good” nature of the market for primary care: if patients are unable to observe quality improvements from training, NPCs have weaker incentives to participate. Empirical evidence is limited on the relationship between market competition and NPC participation in-service training as well as how participation varies with the type of training available. Methods The study uses a dataset of 301 NPCs from three prefectures in Yunnan, a province in southwest China, collected in July 2017. Logistic regression is used to estimate the relationship between competition and NPC’s participation in in-service training. We assess the relationship between participation and both the quantity of competition (number of competitors in the same village and surrounding villages) and the quality of competition (proxied using characteristics of competing clinicians). Results In 2016, nearly two thirds of NPCs participated in face-to-face or web-based in-service trainings at least once. Specifically, 58 percent of NPCs participated in face-to-face in-service trainings, and 24 percent of NPCs participated in web-based in-service trainings. The quantity of competitors is unrelated to participation in in-service training. The quality of competition is not related to face-to-face training but has a significant positive relationship with participation in web-based training. Conclusions Web-based trainings may be a better approach to increase NPC skills in developing country primary care markets.;The study uses a dataset of 301 NPCs from three prefectures in Yunnan, a province in southwest China, collected in July 2017. Logistic regression is used to estimate the relationship between competition and NPC's participation in in-service training. We assess the relationship between participation and both the quantity of competition (number of competitors in the same village and surrounding villages) and the quality of competition (proxied using characteristics of competing clinicians). In 2016, nearly two thirds of NPCs participated in face-to-face or web-based in-service trainings at least once. Specifically, 58 percent of NPCs participated in face-to-face in-service trainings, and 24 percent of NPCs participated in web-based in-service trainings. The quantity of competitors is unrelated to participation in in-service training. The quality of competition is not related to face-to-face training but has a significant positive relationship with participation in web-based training. Web-based trainings may be a better approach to increase NPC skills in developing country primary care markets.;

Chronic diseases can be controlled through effective self-management. The purpose of this study is to explore the regularity of clinical visits and medication adherence of patients with hypertension or diabetes (PWHD), and its association with the first experience with care and individual factors in rural Southwestern China. This cross-sectional study was carried out in Yunnan province in 2018 and recruited 292 PWHD and 122 village clinics from 122 villages in 10 counties. Participants were interviewed using a structured questionnaire. Results show around 39% of hypertensive and 25% of diabetic patients neither visited physicians nor took medicine regularly during the preceding three months of the interview date. The regression results further indicated that individual characteristics of the PWHD, including patient age, health status, and economic level, as well as their first experience with care, were significantly associated with their regular healthcare behavior. In addition to providing medical services, on average each sample village clinic, with around two physicians, simultaneously managed 180 hypertensive and 45 diabetic patients. This study revealed the need for further reforms in terms of improving self-management and thus recommends an increase in the quantity and the quality of human resources in the primary healthcare realm in rural China.

Sustaining multiple ecosystem service benefits in transboundary river basins is a complex and challenging task in the developing world. This can be attributed to conflicting conservation and human development needs and exacerbated by climate change impacts, especially episodic drought and flooding events. We use a case study from Rwanda in the Kagera River Basin in Eastern Africa to contextualize and examine how land use cover change, water access, and agro-ecosystems are vulnerable to myriad human and natural drivers of change. An integrated framework is employed for a nested social-ecological assessment of ecosystem service benefits drawing upon landscape and vulnerability mapping, agro-commodity value chains, and institutional analyses. The conceptual framework and case study provide leverage points for vertical and horizontal linkages that include cross-sectoral partnerships, multi-level governing networks, integrated water resource management, and livelihood security. Moreover, synergy between development and conservation outcomes can be achieved through joint adaptation planning and stewardship initiatives at the local district level with full participation of resource users and community leaders. These lessons from Rwanda and the Kagera River Basin provide opportunities for mainstreaming adaptation and development planning and building resilience towards regional environmental change in Eastern Africa.