Systems of governance play a key role in the operation and performance of health systems. In the past six decades, China has made great advances in strengthening its health system, most notably in establishing a health insurance system that enables residents of rural areas to achieve access to essential services. Although there have been several studies of rural health insurance schemes, these have focused on coverage and service utilization, while much less attention has been given to the role of governance in designing and implementing these schemes. Information from publications and policy documents relevant to the development of two rural health insurance policies in China was obtained, analysed, and synthesise. 92 documents on CMS (Cooperative Medical Scheme) or NCMS (New Rural Cooperative Medical Scheme) from four databases searched were included. Data extraction and synthesis of the information were guided by a framework that drew on that developed by the WHO to describe health system governance and leadership. We identified a series of governance practices that were supportive of progress, including the prioritisation by the central government of health system development and certain health policies within overall national development; strong government commitment combined with a hierarchal administrative system; clear policy goals coupled with the ability for local government to adopt policy measures that take account of local conditions; and the accumulation and use of the evidence generated from local practices. However these good practices were not seen in all governance domains. For example, poor collaboration between different government departments was shown to be a considerable challenge that undermined the operation of the insurance schemes. China’s success in achieving scale up of CMS and NCMS has attracted considerable interest in many low and middle income countries (LMICs), especially with regard to the schemes’ designs, coverage, and funding mechanisms. However, this study demonstrates that health systems governance may be critical to enable the development and operation of such schemes. Given that many LMICs are expanding health financing system to cover populations in rural areas or the informal sectors, we argue that strengthening specific practices in each governance domain could inform the adaptation of these schemes to other settings.

Objective Although China has made remarkable progress in strengthening its primary healthcare system, lack of well-performed primary health workforce is still the bottleneck of deepening the reform. The objective of this review is to understand the current profile of Chinese primary care workers (PCWs) and their motivating factors of performance and propose targeted policy suggestions on improving their work performance. Design Systematic review. Methods A systematic search of PubMed and MEDLINE was conducted to identify articles published from January 1, 2000, to June 2, 2018. Quality assessment and data extraction for the studies closely relevant to performance of PCWs in China were conducted by two reviewers independently. A preliminary framework containing different levels of factors influencing PCWs’ motivation based on existence, growth and relatedness (ERG) theory guided the synthesis analysis. In addition, we used a random-effects model to pool individual studies on job satisfaction and estimate the overall job satisfaction of PCWs. Results A total of 36 articles were included; 16 (23 882 participants) in the meta-analysis. Regarding the individual level of motivation, 3 overarching themes and 12 subthemes were developed. The subthemes of financial incentives, career advancement and work itself were frequently mentioned and have more influences on PCWs’ performance. Moreover, the healthcare system reform policies have inevitable and complex impacts on different levels of human needs, and then influences on the motivation and performance of PCWs. Meta-analysis showed that the overall job satisfaction score among PCWs was 3.30, just reaching a satisfied rating and varied in different regions. Conclusions This study suggests low work satisfaction among PCWs in China, with financial incentives and career advancement being two most important motivating factors. Efforts to improve the work performance in PCWs should give priority to these motivating factors and systematically take into account the health policy’s impacts on performance of PCWs.

Burnout is a common and growing phenomenon in the health care setting. The objective of the present study is to examine contextual factors in the workplace associated with burnout among primary care providers (PCPs) in Shandong Province, China. A cross-sectional survey was conducted among 951 PCPs nested within 48 primary health institutions (PHIs). Burnout was measured using the Maslach Burnout Inventory–Human Services Survey (MBI–HSS). We used two-level random intercept linear regression models to examine individual- versus workplace-level risk factors for burnout. The result revealed that 33.12%, 8.83% and 41.43% PCPs were experiencing a high degree of emotional exhaustion (EE), depersonalization (DP) and low personal accomplishment (PA). In multilevel analysis, the most significant and common individual-level predictors of burnout were lack of perceived work support and autonomy. At the institutional level, workload was positively related to EE (odds ratio (OR): 6.59; 95% confidence interval (CI): 3.46–9.72), while work support was related to higher PA (OR: 3.49; 95% CI: 0.81–6.17). Greater attention should be paid to the influence of the work environment factors (workload and work support) to prevent burnout. Strategies such as increasing human resources allocated to PHIs and establishing a supportive work environment are encouraged to prevent and reduce burnout among PCPs in China.

China has made remarkable progress in scaling up essential services during the last six decades, making health care increasingly available in rural areas. This was partly achieved through the building of a three-tier health system in the 1950s, established as a linked network with health service facilities at county, township and village level, to extend services to the whole population. We developed a Theory of Change to chart the policy context, contents and mechanisms that may have facilitated the establishment of the three-tier health service delivery system in rural China. We systematically synthesized the best available evidence on how China achieved universal access to essential services in resource-scarce rural settings, with a particular emphasis on the experiences learned before the 1980s, when the country suffered a particularly acute lack of resources. The search identified only three peered-reviewed articles that fit our criteria for scientific rigor. We therefore drew extensively on government policy documents, and triangulated them with other publications and key informant interviews. We found that China’s three-tier health service delivery system was established in response to acute health challenges, including high fertility and mortality rates. Health system resources were extremely low in view of the needs and insufficient to extend access to even basic care. With strong political commitment to rural health and a “health-for-all” policy vision underlying implementation, a three-tier health service delivery model connecting villages, townships and counties was quickly established. We identified several factors that contributed to the success of the three-tier system in China: a realistic health human resource development strategy, use of mass campaigns as a vehicle to increase demand, an innovative financing mechanisms, public-private partnership models in the early stages of scale up, and an integrated approach to service delivery. An implementation process involving gradual adaptation and incorporation of the lessons learnt was also essential. China’s 60 year experience in establishing a de-professionalized, community-based, health service delivery model that is economically feasible, institutionally and culturally appropriate mechanism can be useful to other low- and middle-income countries (LMICs) seeking to extend essential services. Lessons can be drawn from both reform content and from its implementation pathway, identifying the political, institutional and contextual factors shaping the three-tier delivery model over time.

Objective Although the herpes zoster vaccine has been available in mainland China since June 2020, residents’ knowledge of herpes zoster and the herpes zoster vaccine is poor, and vaccination rates are low, especially among the elderly, who are at high risk for herpes zoster. This study assessed willingness to be vaccinated against herpes zoster and factors associated with vaccination among urban residents in China. Methods A mixed-methods study was conducted in community health centres from August 2022 to September 2022. We used convenience sampling to select 2864 residents from 9 Chinese cities for the quantitative study and 67 adults for the qualitative study. A structured questionnaire was used for the quantitative study, and data were collected through face-to-face interviews. Multinomial logistic regression was used to analyse factors associated with willingness to vaccinate. Qualitative data were analysed using thematic analysis of barriers to herpes zoster vaccination. Results A total of 2864 eligible respondents were included in the study. Of these, 42.67% intended to receive the herpes zoster vaccine, 21.44% refused and 35.89% were hesitant. The results of the quantitative and qualitative analyses showed that the factors associated with respondents’ willingness to be vaccinated against herpes zoster included: personal characteristics such as gender, age and income; knowledge and attitudes about herpes zoster and the vaccine; vaccine characteristics such as efficacy, safety and price; and other factors such as pain tolerance and accessibility to vaccination. Conclusion The low willingness to vaccinate, especially among the elderly, is mainly related to their poor knowledge and negative attitude towards the infection and vaccination. Therefore, health education about herpes zoster, immunisation promotion, and improvement of accessibility and affordability would be valuable in China.

Background: Development assistance for health (DAH) plays a vital role in supporting health programmes in low- and middle-income countries. While DAH has historically focused on infectious diseases and maternal and child health, there is a lack of comprehensive analysis of DAH trends, strategic shifts and their impact on health systems and outcomes. This study aims to provide a comprehensive review of DAH from 1990 to 2022, examining its evolution and funding allocation shifts.Methods: We conducted a mixed-methods review, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic literature search was performed across PubMed, Embase, Web of Science and the Cochrane databases, yielding 102 eligible studies. Quantitative data were obtained from the Institute for Health Metrics and Evaluation database, covering DAH data from 1990 to 2022. Qualitative data were analysed through thematic synthesis based on the WHO’s six health system building blocks.Results: The DAH has predominantly focused on HIV/AIDS and maternal and child health. Despite the increasing global burden of non-communicable diseases (NCDs), the proportion of DAH allocated to NCDs remained low, increasing only from 1% in 1990 to 2% in 2022. Similarly, the overall funding for health system strengthening decreased from 19% in 1990 to 7% in 2022. Major contributors to DAH included the USA, the UK and the Bill & Melinda Gates Foundation. While associations between DAH and improvements in certain health outcomes were observed, establishing causality is challenging due to multiple influencing factors. The COVID-19 pandemic underscored the importance of robust health systems. However, DAH allocation did not show any substantial shift towards health system strengthening during this period. Economic evaluations calculated the median incremental cost-effectiveness ratio of DAH interventions,Conclusions: This study reviews DAH trends from 1990 to 2022, showing a predominant focus on HIV/AIDS and maternal and child health, with insufficient attention to NCDs and health system strengthening. Despite the increasing burden of NCDs and the impact of COVID-19, DAH priorities have not significantly shifted, highlighting the need for ongoing evaluation and strategic adjustments. To enhance DAH effectiveness, it is crucial to adopt a more balanced approach and also align interventions with needs from recipient countries and implement evidence-based strategies with continuous monitoring and evaluation.