1. Introduction
China is one of the 30 countries with the highest tuberculosis (TB) burden. According to the National TB Epidemiology Survey conducted in 2017, there were approximately 900,000 new TB cases in China. This amount accounted for 9% of the total number of new tuberculosis patients worldwide and was the second largest TB epidemic in the world [
1,
2]. Due to the serious situation of TB in China, many interventions have been implemented in recent years, including the nationwide scale-up of the WHO-recommended the directly observed therapy, short-course (DOTS) strategy and a comprehensive program for multi-drug resistant tuberculosis (MDR-TB). Such initiatives have led to an impressive decline in pulmonary TB [
3].
However, several factors add to the financial barriers for poor patients to access TB treatment in China. One of the main factors is poverty [
4]. Due to the economic costs involved, the poor are more likely to develop tuberculosis and face greater financial barriers to quality treatment. A national TB survey in China in 2010 showed that 10% of tuberculosis patients received intermittent treatment, and another 22% discontinued before completing the treatment process [
5]. Around 68% patients finished their regular TB treatment in China. Compared with 76% in Timor-Leste [
6] and 83.3% in Indian [
7], it was much lower than other low- and middle-income countries (LMICs). Economic difficulties were the reason for their abandonment of treatment, which was reported by 15% of patients who discontinued treatment. Research has also mentioned that poverty can lead to interruptions in TB treatment, especially in the first two months of starting treatment [
8,
9]. In addition, geographic distance significantly influences the seeking of active TB treatment [
10]. Patients living in remote rural areas face more difficulties in early service utilization. They must consider the costs of transportation and accommodation involved in seeking outpatient or inpatient services [
11]. Another factor, public health financing programs, was proven to be important for TB treatment, especially in LMICs where the resource is limited [
12]. Effective public health financing could alleviate the financial burden of TB patients and avert most cases of poverty [
13].
In the context of universal health coverage, the China National Health and Family Planning Commission (NHFPC)–The Bill & Melinda Gates Foundation TB Phase II program (the ‘China–Gates TB Project’) was implemented between 2012 and 2015 in three prefectures in three cities in China. The new TB financing and payment model included increasing health insurance reimbursement rates for hospitalization and outpatient TB services, changing the provider payment method to a case-based payment from the current fee-for-service, and providing transportation and subsistence financial incentives to TB patients who adhered to treatment. The components were documented in a previous study [
14].
TB is a communicable disease that is often associated with poverty and hardship, and disparities in terms of both disease prevalence rate and access to diagnosis and treatment are well established and widespread [
15,
16]. Many previous studies have examined equity issues related to geographic locations, gender, and the socio-economic status of TB patients [
17,
18,
19,
20]. Moreover, rich international literature has suggested that public subsidies for health programs frequently benefit richer people more than poorer people [
21,
22,
23]. Whether a health insurance-based approach can effectively target the poor is therefore of great concern. In this study, we provide an evaluation of the China–Gates TB Project on TB health utilization in a central area of China. We aimed to determine (1) whether the China–Gates TB Project increased outpatient visits and inpatient hospitalization utilization rates and (2) whether the China–Gates TB Project increased the use of TB health services similarly across income and county subgroups. Our findings quantitatively and qualitatively assess tuberculosis financing and payment model performance relative to the health improvements and may contribute to improving and adjusting the China–Gates TB Project policy, thereby further relieving the inequity in healthcare.
4. Discussion
Overall, the China–Gates TB program Phase II was found to improve TB health utilization, no matter the outpatient visit or inpatient admission rates. The program effects were greater for the low income groups compared to the richest group. The effect of the intervention was significantly different between counties. The number of outpatient visits increased the most in the remote county (WF).
Case-based payments contributed to the increased TB health utilization after the project. New payment methods effectively decreased the out-of-pocket medical payments of TB patients. For outpatient visits, rural TB patients were basically treated at their own expense with a low outpatient reimbursement rate before the project was launched. After the project, patients only paid 20% of the total medical expenditure for outpatient visits, with a 780 CNY (US
$ 125) cap. Qualitative interviews also proved this result. Furthermore, “fee-for-service” payment has been proven to be another major factor affecting the use of TB health services in China [
37]. Physicians in different health facilities would prescribe repeated examinations and treatments with income incentives, causing a delay of TB diagnosis, a high cost, and poor effects of the treatment. The shift from fee-for-service to case-based payment can effectively reduce the negative impression of patients and promote the use of outpatient and inpatient services.
Compared with the rich, the hospitalization and outpatient services of the poor increased more. With rich interview material from FGDs, the pro-poor effects can be explained by two reasons: On the one hand, transport and subsistence allowances provided strong incentives to poor patients, many of who live in remote rural areas and have higher transportation costs, to seek care. Financial or material incentives such as food, transportation subsidies, and/or money were considered to be effective at reducing the direct and opportunity costs of treatment [
38,
39]. Travel subsidies to get to a clinic for TB patients were used in other studies in China [
40,
41] but did not reach the poor tuberculosis patients because they provided an inadequate amount (only US
$ 1 for the first visit). In this project, about US
$ 10 were given to TB patients per month. Higher financial incentives could perform better. On the other hand, medical financial assistance was provided by the Department of Civil Affairs for eligible low-income households, further reducing their financial burden.
Why did the higher incomes group not have the most growth? For the wealthier patients, there is less potential health services demand. The price elasticity of health service demands is small. Even if the reimbursement rate was increased, they would not significantly increase their utilization of health services. This result is inconsistent with many other studies. Rao and Peters [
42] noted that public health interventions sometimes benefit the wealthy, given that the better-off are more likely to use health services when they are ill. Victora et al. [
43] found that maternal and child health interventions initially increased but then reduced inequality. The interventions were first accessed by richer households but were then taken up by the poor. The reasons for the difference may be that there are special subsidies that tilt the policies to benefit the poor in this project.
The difference in effect between counties is obvious. As an underdeveloped mountainous county, patients in WF preferred to increase outpatient services rather than inpatient ones. Qualitative results from the study indicate several possible reasons. TB patients generally go to the outpatient clinics in the county and go to the Yichang municipal medical institutions for hospitalization. The cost of outpatient visits is lower, and due to their living in an undeveloped area, tuberculosis patients in WF are more sensitive to outpatient services. They also want to make more use of inpatient services, but the cost of hospitalization is high. In addition, hospital accommodation, transportation, accommodation and other expenses are also economic barriers. WF is the farthest county away from Yichang city. The mountainous terrain has caused local traffic inconveniences. If patients go to the city to seek inpatient services, the cost of transportation and accommodation will be much higher than for other counties. In the rural mountainous areas of China, limited transportation, poverty and poor primary health services may make medical services for diagnosis and treatment of tuberculosis worse [
44]. In terms of cost-effectiveness, the differences between counties are still obvious. WF had the best cost-effectiveness in outpatient intervention, while YD had the best in inpatient services utilization. This finding suggests that we should consider regional differences when implementing projects and give more transportation and living subsidies to counties with inconvenient transportation. The FGDs also showed physicians’ attitude was another reason for outpatient visits. The increased outpatient visits and inpatient admission rate suggest that TB health services utilization improved. However, does it truly indicate a ‘good’ improvement? Currently, TB treatment guidelines by the WHO and China CDC recommend that rifampicin-sensitive newly diagnosed TB patients should receive six months of outpatient treatment, and relapsed TB patients should receive eight months. The increase in the overall average number of outpatient visits from 4.6 to 5.6 implies that more TB patients received outpatient treatment in line with the standard (six-to-eight visits) recommended by the WHO guideline and the standard of outpatient diagnosis and treatment of tuberculosis in China [
45], which can be seen as a beneficial change. However, the sharp rise in the inpatient rate, from 33.5% to 75.9%, is contrary to the recommended treatment guidelines [
46,
47], which indicate that only patients with serious complications or severe adverse reactions require hospitalization. Compared with other studies, the observed inpatient rate appears excessive. For example, the hospitalization rate of TB patients was 54% in Montreal, Canada [
48] and 66% in Spain [
49]. High impatient rates increase the financial burden on patients and may overload treatment facilities [
50]. Thus, this apparent improvement in inpatient services utilization cannot be seen as uniformly beneficial.
This study has several limitations. First, there was very limited quantitative information on patient case-mix and service details (such as prescriptions and procedures). Therefore, the appropriateness and quality of services cannot be assessed objectively. Second, the study was not a randomized controlled study. We evaluated the impact of the new project with pooled cross-section data before and after intervention. However, various biases may occur in implementation. China is implementing health system reforms, and there were multiple concurrent policy interventions that may be synergistic or antagonistic. These confounding factors may lead to a biased estimate of the role of the China–Gates TB Project on the outcomes. Thirdly, the results of this study can provide a reference for areas with similar economic development levels in central China. However, considering that the study included three counties within one city in China, there are limits to extending the results of this sample to all regions.