Performance evaluations, trust and utilization of health care in China
Introduction
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 is 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 health in China 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 is the first systematic study of these attitudes and how they influence utilization.
Methodology
Using a special purpose questionnaire, we commissioned a nationwide survey in mainland China. Fieldwork was carried out from 1 November 2012 to 17 January 2013 by the Research Center for Contemporary China at Peking University. The target population was mainland Chinese citizens age 18 to 70 residing for more than 30 days in family dwellings in all 31 provinces. The survey used the GPS Assisted Area Sampling Method (Landry & Shen, 2005) to project a grid onto 2855 counties, county-level cities or urban districts of the same status. Stratification took place in stages. At the first stage, the country was divided into three official macro-regions, Eastern, Central and
Western; each macro-region was divided into urban and rural administrative areas, giving six layers in total; 60 primary sampling units (PSU) corresponding to county-level administrative divisions were selected at random across the six layers with probability proportionate to population. Within each PSU, three half-square minutes (HSM) of latitude and longitude were chosen with probability proportionate to population density, within each of these, again proportionate to population density, a number of spatial square seconds (SSS) corresponding to 90m x 90m squares was selected at random. Within each SSS, all dwellings were enumerated, and 27 were selected in each HSM by systematic sampling. Within each dwelling respondents were identified by the Kish method. The completed questionnaires were collected, checked, and signed by the field supervisors on location and verified for validity during database creation. To minimize deviation from national 2010 census characteristics, weighting and post stratification was done by age and gender. The result was a sample of 5,424 dwellings in which 3,684 valid interviews were completed, giving a response rate of 67.9 per cent.
MAP OF PRIMARY SAMPLING UNITS
In June and July 2012, we also held nine focus group discussions (FGDs) at five locations divided as follows. Five FGDs were held across the urban/rural divide, with three in a poor city, Chifeng in Inner Mongolia, and two in a rich city, Shaoxing, Zhejiang Province. For these FGDs, participants were recruited across the general population age 35 years and above, with a mix by age, gender, income and employment. Four FGDs were held in a middle income prefecture-level city, Yueyang, Hunan Province. Participants were patients who had been treated at a hospital or clinic within the last two weeks for an illness or injury, with stratification according to whether the illness was chronic or acute and whether or not the respondent had insurance equivalent to the Urban Employees Basic Medical Insurance (UEBMI) scheme or better. As it happened, difficulties in recruitment meant that the each focus group contained participants with a mixture of chronic and acute conditions. Medical conditions were recorded during recruitment. A few respondents age 30 to 35 were allowed to take part. The FGDs were an important element in the process of designing the survey questionnaire.
Data and documentation for the study can be accessed from the UK Data Archive here: https://beta.ukdataservice.ac.uk/datacatalogue/studies/study?id=852091
Target
Our findings will be of interest to businesses, NGOs and Chinese health policy makers by providing new information 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 combines 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 produces a major dataset enabling UK and international researchers to study the relationships between attitudes and behaviour in the Chinese healthcare system. It develops 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 benefit 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. 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.
We are currently in the process of analysing the results which we will make available through our publications. The full data set and bilingual focus group transcripts together with all relevant documentation will be submitted to the UK Data Archive at the end of the project.
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Outputs
Duckett, J. 2013. Introduction to the Project: ‘Performance Evaluations, Trust and the Utilization of Health Care’. Paper presented at China’s Health Reforms after Four Years: Public Evaluations, workshop at Peking University, 16 September
Journal articles
Duckett, J., K. Hunt, N. Munro and M. Sutton (2016) Does distrust in providers affect health-care utilization in China? Health Policy and Planning DOI: 10.1093/heapol/czw024
Munro, N. & Duckett, J. 2015. Explaining public satisfaction with health-care systems: findings from a nationwide survey in China. Health Expectations 16(3):654-666. DOI: 10.1111/hex.12429
Full data Set
Data and documentation for the study can be found at the UK Data Archive site here: https://beta.ukdataservice.ac.uk/datacatalogue/studies/study?id=852091
Briefing paper
Are Chinese people satisfied with their health care system?
Conference papers
Duckett, J., et al. 2013. Public attitudes toward health provision in China: is there demand for equal access and public provision? Paper presented at Association for Asian Studies Annual Conference, San Diego, 23 March.
Hunt, K. , 2013. about attitudes to health care provision and reform in China. Paper presented at China’s Health Reforms after Four Years: Public Evaluations, workshop at Peking University, 16 September
Munro, N. 2013. Strategies for dealing with non-fiduciary prescribing: a policy-centred analysis: a policy-centred analysis. Paper presented at China’s Health Reforms after Four Years: Public Evaluations, workshop at Peking University, 16 September
Munro, N., 2013. The effects of performance evaluations and trust on popular strategies for dealing with uncertainty about the outcome of critical surgery. Keynote speech at conference Violence towards healthcare professionals: an assessment of causes, frequency, prevention and solutions, University of Chicago Center, Beijing, 17 September
Munro, N. et al. , 2013. Use of Guanxi and other strategies in dealing with the Chinese health care system. Paper presented at the Association for Asian Studies Annual Conference, San Diego, 22 March.
Munro, N. et al., 2013. Does China’s Regime Enjoy “Performance Legitimacy”? An Empirical Analysis Based on Three Surveys from the Past Decade. Paper presented at American Political Science Association Annual Conference, Chicago, 29 August-1 September
Sutton, M., 2013. . Paper presented at China’s Health Reforms after Four Years: Public Evaluations, workshop at Peking University, 16 September
Who We Are
This project is led from the University of Glasgow by:
Professor Jane Duckett (Principal Investigator) with Co-Investigators:
Dr Neil Munro (University of Glasgow)
Professor Kate Hunt (University of Glasgow) and
Professor Matt Sutton (University of Manchester).
It is funded under Economic and Social Research Council (ESRC), project grant number ES/J011487/1.
Project news
Prof Jane Duckett (University of Glasgow) organized a conference on ‘The Sustainability of Health Care Systems: Evaluations, Trust and Utilisation’ on 2 February 2015 at the British Academy, London. Conference programme. The following day, a half-day conference entitled "Popular Attitudes the Health Care System in China," aimed at non-academic users, was held at the same venue.
China’s Health Reforms after Four Years: Public Evaluations Workshop 16 September 2013, Peking University
Report on the conference on "Violence towards healthcare professionals: an assessment of causes, frequency, prevention and solutions", University of Chicago Center, Beijing, 17-18 Septemberi 2013. The report appeared in n Medical World, a Chinese language newspaper aimed at health care professionals: http://www.yxj.org.cn/news/yishirenwen/yishizhatan/2013092809010829171.htm