Performance of the health system in China and Asia as measured by responsiveness

doi:10.4236/health.2011.310108

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Vol.3, No.10, 638-646 (2011)

doi:10.4236/health.2011.310108

Health

Performance of the health system in China and Asia as

measured by responsiveness

Paul Kowal1,2*, Nirmala Naidoo1, Sharon Renee Williams3, Somnath Chatterji1

1World Health Organization, Department of Health Statistics and Information Systems, Multi-Country Studies unit, Geneva, Switzer-

land; *Corresponding author: kowalp@who.int

2University of Newcastle, Priority Research Centre on Gender, Health and Ageing, Newcastle, New South Wales, Australia;

3Purdue University, Department of Anthropology, West Lafayette, USA.

Received 13 July 2011; revised 9 August 2011; accepted 31 August 2011.

ABSTRACT

Objectives: To examine differences in health

system re sponsiveness across different secto rs

in China and to compare to other Asian coun-

tries. Methods: The World Health Survey was

implemented in a nationally representative sam-

ple in China and 10 additional Asian countries

from 2002-2003. Face-to-face interviews were

conducted to gather health care utilization and

health systems responsiveness data. Results:

Overall health system responsiveness in China

was better for the inpatient than the outpatient

health system. Differences were seen by do-

main, with pr ompt a tte nti on a nd re spec tful treat-

ment performing better than the other domains.

Differences in responsiveness were seen by

socio-demographic characteristics, w ith women

and younger respondents rating inpatient sys-

tems, whereas men and higher educated respon-

dents rated outpat ient systems, more re sponsive.

Conclusions: As populations age, health care

systems will come under more pressures—res-

ponsiveness can be used by governments to

guide policy and system improvement efforts

when resources are limited. In China, reforms

might prioritize outpatient system responsive-

ness.

Keywords: Ageing; Adult Health; Health;

Planning; Health Policy; Health Systems

1. INTRODUCTION

Responsiveness of a health care system involves as-

sessing individual experiences. Compiling these experi-

ences at a population level provide valuable inputs for

policy and planning, especially for a country like China

which has gone thro ugh significant changes in their sys-

tems over the past few decades (health policies in the

1970’s (“barefoot” doctors to private health care) and

social policies in 1980’s (in particular, related to fertility))

and the ongoing health transition [1-6]. By 2030, older

adults will bear two-thirds of the total disease burden in

China [2]. Before the year 2020, the number of people

aged 60 years and older in China will exceed the number

of people younger than 15 years. [7]

The economic impacts for society increasingly con-

cerned with adult health needs may be mitigated by a

highly responsive health care system. It is anticipated

that a responsive health system contributes to improved

health outcomes and cost-efficiencies [8,9]. Responsive-

ness will be one mechanism for monitoring how well the

health care system adapts to future population health

profiles.

WHO developed responsiveness as a concept primar-

ily to evaluate general health care systems on a national

level. It has also been applied to specific services within

a health care system [10,11]. Health system responsive-

ness is related to both what actually transpires when pa-

tients come into contact with the health system and the

environment in which they are treated [12-15]. It is in-

fluenced by interactions with the health system and is a

key outcome measure for assessing the performance of a

health care system. A common set of eight domains

forms the basis for measuring responsiveness and are

commonly arranged into interpersonal and structural

groupings. In a previous study, Chinese respondents

rated prompt attention and dignity well ahead of the

other dom ains [16].

The first objective was to identify differences in re-

sponsiveness by age, sex, health state and type of care

used (inpatient or outpatient); the second to create an

overall responsiveness variable, adjusted by vignette

ratings; the third to identify predictors of health system

responsiveness in China; and finally, to compare China

to a number of other countries in the region.

P. Kowal et al. / Health 3 (2011) 638-646

639639

Overall health and responsiveness scores were gener-

ated for the Chinese health system for the World Health

Survey. Each of the scores condenses multiple dimensions

into a summary score and was adjusted by u se of anchor-

ing vignette methods to improve data comparability. The

components and distributions of both scores are presented

here across various population characteristics. Addition-

ally, health system responsiveness scores for six countries

in south and south-eastern Asia were generated to com-

pare with the Chinese health system responsiveness re-

sults, as a means to put the results into some perspective.

2. METHODS

2.1. Data

Weighted data from the World Health Survey China

2002 was used for this analysis. The WHS was imple-

mented as a face-to-face household survey with the

sample drawn from a current frame using a stratified,

multi-stage cluster design to allow each household and

individual respondent to be assigned a known non-zero

probability of selection. More information about the

WHS sampling and data collection are available in pre-

vious publications [17]. In China, the survey was carried

out in Gansu, Guangdong (including Shengzhen city),

Hebei, Hubei, Jiangsu, Shaanxi, Sichuan and Zhejiang

provinces. Of the other countries, India’s survey was

implemented in a nationally repr esentative sa mple, using

multi-stage sampling, and random selection of six states

that represent 96% of the population, while the Philip-

pines, Malaysia, Nepal, Sri Lanka, and Viet Nam all

used nationally representative samples.

The responsiveness results are categorized into two

groups, each consisting of four domains. Table 1 also

provides brief descriptions of what the domain covers,

and the topic of questions asked during the interviews.

Table 1. Responsiveness groupings, domains and definitions.

Group Domain Definitions

Dignity Talked respectfully

Privacy

Communication Clear explanations

Time for questions

Autonomy Treatment information

Patient involvement

Interpersonal

Confidentiality Talk privately

Confidentiality of reco r ds

Choice of Health Care

Provider Choice of provider

Quality of Basic

Amenities Cleanliness

Space

Access to Support Family visit

External contact

Structural

Prompt Attention Travel time

Wait time

Source: Va le ntine 2003.

2.2. Analyses

Distributions of responsiveness by age groups, sex,

health score and inpatient and outpatient care use was

carried out using bivariate analyses. Data from the vari-

ous responsiveness domains were analysed using the

Compound Hierarchical Ordered Probit Model [18] to

adjust for systematic reporting biases across respondents.

The covariates used in the model were age, sex and in-

come quintiles. Each domain of responsiveness was first

estimated as a score on a latent variable scale and then

transformed from 0 - 100 where 0 indicates worst and

100 indicates best responsiveness. The “choice” domain

was dropped from both inpatient and outpatient calcula-

tions, whilst the “social support” variable was not appli-

cable for outpatient care. A confirmatory factor analysis

was then carried out with the scores from the seven indi-

vidual domains for a one factor solu tion. The factor load

ings were then used to create an overall composite score

across the different domains and this was rescaled from

0-100 as was done with the individual domain scores.

Analyses were carried out using the probability weights

and variance estimations, taking into account the com-

plex survey design with the Taylor series method using

STATA 11.0.

3. RESULTS

The sample size was 3993 with response rate of 92.8%

(Table 2). This included 19.1% of respondents aged 60

Table 2. Percent distribution of men and women by age, resi-

dence, marital status and education, China 2003.

MaleSE Female SE TotalSE

Age

18 - 29 16.51.4 20.1 1.5 18.31.2

30 - 44 32.22.5 32.2 3 32.22.5

45 - 59 31 2 29.7 1.7 30.41.6

60 - 69 11.71 9.5 0.6 10.60.5

70 - 79 6.4 0.9 6.9 1.2 6.6 0.9

80+ 2.3 0.5 1.5 0.3 1.9 0.3

Residence

Urban 30.24.8 31.4 4 30.84.3

Rural 69.84.8 66.6 4 69.24.3

Marital status

Never 12.71.1 10 0.8 11.40.8

Currently married82.61.1 81.2 1.4 81.90.7

Separated 0.1 0 0.1 0 0.1 0

Divorced 0.7 0.2 0.8 0.2 0.7 0.2

Widowed 3.8 0.6 7.9 1.2 5.9 0.7

Cohabiting 0.2 0.1 0.1 0.1 0.1 0.1

Education

No formal 4.9 0.8 16.2 1.5 10.71

Less than primary9.8 1.9 9.6 1.2 9.7 1.5

Primary 23.91.6 25.2 2.2 24.51.6

Secondary 34.12 26.2 2 30.11.6

High school 16.11.4 14.7 1.3 15.40.7

College 10.72.4 8 1.5 9.3 1.8

Post-graduate 0.5 0.1 0.1 0.1 0.3 0.1

Total 1957 2036 3993

Source: World Health Survey, 2003.

P. Kowal et al. / Health 3 (2011) 638-646

640

years and older, 51.1% female, 10.6% with no formal

education, 82% currently married or cohabiting and

69.2% rural living. Less than 8% of the sample rated

their overall general health as bad or very bad. Using the

multi-dimensional construct for estimating health status,

average health scores were better for men, urban dwell-

ers and households with higher income [2]. Females

were more likely to use inpatient (59%) and outpatient

(57%) services. Just over 12% (N = 488) of re spondents

had an overnight stay in a health care facility in the last

year and over 35% (N = 1191) used ambulatory care

services.

Openly accessible at

3.1. Mean Responsiveness Scores by

Respondent Characteristics

Sex, age and socio-economic characteristics influen-

ced the experiences with the health care system. Chinese

women, younger respondents, rural dwellers, lower in-

come and education levels rated inpatient system respon-

siveness better (see Figure 1). Conversely, men, older

respondents and higher socio-economic status respon-

dents rated outpatient system responsiveness higher.

For inpatient care, the sex differences in responsive-

ness was largest for the confidentiality, social support

and prompt attention domains. Clear age differences in

responsiveness were seen for autonomy, social support,

communication, quality of amenities and prompt atten-

tion. Urban and rural dwellers differed in rating quality

of basic amenities. Ratings for the income quintiles were

largely similar, except for the poorest rating quality of

amenities higher than wealthiest and wealthiest rating

social support better than poorest.

Inpatient ResponsivenessOutpatient Responsiveness

Female

Male

A ge: 18-29

A ge: 80+

Urban

Rural

No educ at i on

12+ yrs educat i on

Q1(poorest)

Q5(richest)

Total

Figure 1. Mean overall responsiveness scores (on scale of 0 - 100) for inpatient and outpatient systems by selected respondent char-

acteristics, China 2003.

P. Kowal et al. / Health 3 (2011) 638-646

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For outpatient care, the magnitude of sex differences

was smaller for all domains, with the largest differences

for respectful treatment, communication and prompt

attention. Older respondents indicated better ratings for

prompt attention, communication and quality of ameni-

ties, whilst younger respondents rated confidentiality

and autonomy much better. Urban and rural dwellers had

similar ratings for all domains, except for the communi-

cation and quality of amenities domains. Socio-eco-

nomic status did not report large differences except for

confidentiality.

3.2. Mean Responsiveness Scores by

Domain

Overall responsiveness was better for the inpatient

than outpatient care system. The overall scores by do-

main were similar, with the greatest difference seen in

the communication domain when comparing inpatient

and outpatient responsiveness (see Figure 2). The vari-

ability in ratings across domains were larger for outpa-

tient care than inpatient care.

3.3. Rank Ordering of the Responsiveness

Domains

The importance of the domains, essentially a valuation of

the domains, were ranked using the overall mean results for

each domain. Dignity/respectful treatment and perceived

quality of basic amenities were the two highest ranking

domains across all selected socio-demographic charac-

teristics (see Table 3). Social support and autonomy

were generally ranked lowest. No sex differences were

seen in ranking the remaining four domains, but with

some differences in ranking by urban/rural location, in-

come quintile and age groupings. The lowest income

quintile ranked confidentiality, prompt attention and

choice domains, whilst the highest income quintile re-

spondents ranked confidentiality, communication and

prompt attention in the third, fourth and fifth spots

respectively.

3.4. Domain Scores by Region/Province

Sichuan, Shaanxi, Jiangsu and Shanxi had the highest

overall mean responsiveness scores for inpatient care,

with Hebei the lowest (see Table 4). Sichuan, Shaanxi and

Hebei had much higher standard errors than Jiangsu and

Shanxi provinces. Similarly, outpatient care in Sichuan

and Jiangsu had high overall scores as compared to the

other provinces. Again, respondents in Hebei reported the

lowest responsiveness scores for the health care system,

but was joined by low scores from respondents using am-

bulatory care services in Zhejiang. The largest disparity

between inpatient and outpatient responsiveness was

100

Prompt attention

Respectful Treatm ent

Commu nication

uality of Basic Amenit ies

Confidentiality

Social Support

Autonomy

Overall Responsiveness

Inpatient totalOutpatient total

Figure 2. Me a n domain-specific and overall responsiveness scores for inpatient and outpatient care systems, China 2003.

P. Kowal et al. / Health 3 (2011) 638-646

642

Table 3. Rankings of importance of responsive domain by selected social and demographic variables*, China 2003.

Overall Male Female Urban Rural Low SESHigh SES Age < 50 Age 50+

Dignity/respect 1 1 1 1 1 1 1 1 1

Confidentiality 4 4 4 5 3 3 3 3 5

Prompt attention 3 3 3 3 4 4 5 4 3

Choice 6 6 6 6 6 5 6 6 6

Autonomy 7 7 7 7 7 7 8 7 7

Quality 2 2 2 2 2 2 2 2 2

Access to support 8 8 8 8 8 8 7 8 8

Communication 5 5 5 4 5 6 4 5 4

* Where 1 = highest ranking (highest importance) and 8 = lowest ranking.

Table 4. Mean overall responsiveness scores for regions/provinces, by inpatient or outpatient care use, China 2003.

Inpatient Outpatient

Region/province Mean SE Mean SE

Jiangsu 58.7 0.8 53.3 2.5

Guangdong excluding Shenzhen 55.3 2.5 49.5 1.1

Guangdong 44.6 2.4 44.1 1.0

Shanxi 58.0 1.2 48.0 4.7

Zhejiang 47.0 3.5 37.4 5.1

Hebei 38.1 5.2 34.1 4.7

Hubei 50.0 1.9 44.9 2.9

Sichuan 59.1 6.5 58.0 2.9

Gansu 52.9 6.3 49.2 1.2

Shaanxi 59.0 5.7 49.7 4.0

Total 53.0 1.4 48.5 1.3

was seen in Shanxi province. Most consistent was Si-

chuan province .

3.5. Responsiveness in Countries of South

and South-East Asia

Mean responsiveness scores for both inpatient and

outpatient health systems were generated for an addi-

tional six countries, India, Malaysia, Nepal, the Philip-

pines, Sri Lanka and Viet Nam (see Tab le 5). As health

systems responsiveness is a relatively new concept, re-

sults for these additional countries were inclu ded to situ-

ate the Chinese results in a regional context.

The mean overall inpatient responsiveness score for

China (53.1) was similar to Malaysia (52.7), and the

Philippines (53.7). Inpatient responsiveness was second

highest after the Philippines. Women rated responsive-

ness better in all countries ex cept Viet Nam. China, India

and Sri Lanka did not have distinct patterns by age

groups, whereas responsiveness improved with increase-

ing age in the other four countries. China and Viet Nam

shared a pattern of better responsiveness in rural areas,

in contrast to better responsiveness in urban areas seen

in India and the Philippines. Responsiveness levels were

largely better in lower than higher income quintiles—

unique to the Chinese results.

China’s mean overall outpatient responsiveness score

(48.5) was in the lower tier of scores and comparable to

India, Sri Lanka and Nepal. Chinese and Sri Lankan men

rated outpatient responsiveness better than women, in

contrast to the other countries and to inpatient care

results.

4. DISCUSSION

Future burden of disease patterns in China indicate

greater adult health needs, yet with some indications of an

adult population going through a healthy ageing process,

leading to uncertain implications for health care utilization.

[2,19,20]. A better understanding of the relative impor-

tance of the specific responsiveness domains, and putting

overall scores into context, will assist with health policy

and planning for a Chinese health system at a crossroads

[13,15,21]. Heal th co nd ition s pr edetermine th e p ro bab ility

of health service utilization, and providing information

about a system’s responsiveness will help to maximize th e

efficiency of future care systems.

When comparing results from th e two largest countries,

China and India for example, we see similar patterns

with better responsiveness of inpatient versus outpatient

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Table 5. Inpatient and outpatient system responsiveness mean scores by country and select socio-demographic characteristics.

Inpatient

China SE India SE Sri LankaSE MalaysiaSE NepalSE Philippines SE Viet NamSE

Gender

Female 54.0 0.70 48.6 0.55 48.1 0.8753.0 0.3649.10.46 53.8 0.84 49.2 0.94

Male 52.1 1.21 48.3 0.56 47.1 0.6052.2 0.5448.70.58 53.3 0.68 51.1 1.18

Age

18 - 29 55.1 1.39 48.6 0.71 46.4 0.9451.8 0.6048.40.53 53.3 0.83 48.5 1.16

30 - 44 52.3 0.93 48.1 0.65 47.4 0.6653.0 0.3749.10.69 53.4 0.98 50.4 1.02

45 - 59 54.8 0.91 48.4 1.11 48.8 0.9452.7 0.7348.20.84 53.9 0.74 50.4 1.50

60 - 69 49.9 2.20 49.7 1.21 50.8 1.2854.7 1.1651.01.46 54.5 1.09 51.2 2.04

70 - 79 50.9 1.09 47.3 1.32 46.6 1.1055.4 1.1952.21.63 56.1 2.06 52.7 1.90

80+ 53.9 1.99 54.7 2.94 46.0 2.8956.8 1.6551.22.89 55.1 3.60 50.8 5.16

Residence

Urban 51.2 1.06 51.7 0.76 47.1 2.2252.8 0.4549.80.78 54.7 0.92 47.8 1.41

Rural 54.1 0.95 47.9 0.53 47.7 0.5752.6 0.3848.70.44 51.9 0.65 51.0 1.18

Education

0 55.2 2.66 48.0 0.78 51.7 1.7055.4 0.8148.90.60 50.9 3.02 47.6 2.54

1 - 5 54.2 1.25 48.5 0.69 46.0 0.8753.2 0.8549.11.05 51.8 1.21 50.2 1.23

6 - 11 53.2 0.80 48.3 0.73 47.2 0.6652.3 0.3948.80.67 53.6 0.76 50.0 1.31

12+ 50.7 1.20 51.0 0.90 49.8 1.2052.7 0.6749.21.16 54.7 0.81 50.5 1.95

Income

Q1(poorest) 56.4 1.55 44.4 0.84 47.1 1.2053.3 0.6247.01.05 51.7 1.04 48.8 1.21

Q2 53.1 1.23 46.0 1.05 47.0 0.7352.0 0.6248.00.79 51.5 0.95 49.9 1.33

Q3 53.7 1.21 48.6 0.69 48.1 0.7951.7 0.5850.31.00 52.7 1.20 50.4 1.51

Q4 52.1 1.06 50.6 0.63 46.7 0.9653.3 0.6349.50.83 55.0 1.14 49.9 0.97

Q5(richest) 52.3 1.63 51.7 1.00 49.0 1.1153.6 0.5948.70.70 55.5 0.86 50.9 2.07

Total 53.1 0.75 48.5 0.47 47.6 0.5752.7 0.3248.90.39 53.7 0.63 50.1 0.98

Outpatient

China SE India SE Sri LankaSE MalaysiaSE NepalSE Philippines SE Viet NamSE

Gender

Female 52.2 1.07 51.8 0.50 51.6 0.5157.8 0.3252.50.49 58.1 0.54 54.5 0.73

Male 53.1 0.95 51.7 0.49 51.8 0.5656.5 0.3252.30.52 56.6 0.58 54.5 0.93

Age

18 - 29 53.0 1.09 51.6 0.53 52.4 0.7355.9 0.4052.20.54 57.5 0.73 53.6 0.89

30 - 44 51.7 1.52 51.7 0.50 51.1 0.4957.1 0.4052.60.59 56.8 0.57 55.1 0.79

45 - 59 53.5 0.89 52.1 0.65 51.2 0.8158.0 0.4252.10.76 57.6 0.64 54.2 0.97

60 - 69 52.7 0.87 52.3 0.77 52.0 0.8758.3 0.7852.40.80 58.2 1.01 55.1 1.57

70 - 79 51.1 1.49 49.5 2.36 52.6 0.8558.1 1.0155.82.29 58.8 1.49 53.8 1.20

80+ 54.8 2.67 51.1 2.24 54.1 2.8360.1 2.4257.33.41 58.9 1.59 61.9 5.08

Residence

Urban 52.2 0.87 56.4 0.62 53.3 0.6957.3 0.2853.71.46 58.6 0.65 51.9 1.62

Rural 52.7 1.05 51.0 0.44 51.4 0.5456.6 0.3952.20.39 55.5 0.61 55.5 0.84

Education

0 52.2 1.34 50.5 0.64 51.4 1.8757.7 0.7052.30.51 53.0 2.21 57.7 2.26

1 - 5 53.2 0.99 52.3 0.55 49.0 0.8558.1 0.8051.60.72 55.0 0.73 53.9 1.00

6 - 11 52.3 1.45 52.2 0.49 51.8 0.5556.9 0.2953.20.68 57.4 0.55 54.1 0.74

12+ 53.1 0.97 54.1 0.69 53.1 0.6956.8 0.4952.21.16 59.3 0.67

55.7 1.34

Income

Q1(poorest) 52.7 1.63 49.1 0.75 49.9 0.9656.3 0.5450.40.85 55.1 0.72 54.2 1.36

Q2 53.0 0.98 48.1 0.68 50.4 0.8857.6 0.5252.10.76 55.5 0.74 54.6 0.95

Q3 52.7 1.25 51.5 0.60 51.4 0.9856.2 0.5451.90.61 57.3 0.89 54.0 0.91

Q4 51.1 1.24 53.9 0.63 51.9 0.6356.1 0.4652.10.62 57.4 0.64 54.1 1.09

Q5(richest) 53.8 1.07 56.0 0.55 52.6 0.6258.6 0.5053.5 0.98 59.9 0.77 55.2 1.49

Total 52.6 0.88 51.7 0.41 51.7 0.4857.1 0.2352.40.42 57.4 0.47 54.5 0.76

Source: WHO 2007. www.who.int/healthinfo/survey/en/index.html

P. Kowal et al. / Health 3 (2011) 638-646

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systems, and largely similar ranking of domain valua-

tions by sex, age, economic status and location. However,

China had significantly higher responsiveness scores

than India. These results were adjusted using vignette

methodologies to improve cross-country comparability

of the data, so some of the potential biases are removed.

The authors can only speculate as to some of the reasons,

including differences in population sex ratio imbalances,

GDP per capita, health status (with health improving

faster in India than China over the two decades from

1980-2000 [22], but larger gains in life expectancy and

disease prevention in China than India over the past half

century [23], age structures, access to private health care

(which may then alter expectations in relation to public

health care systems) or greater availability of primary

care services or national health expend itures. Some clu es

might lie in closer investigation of similar scores by re-

gion in each country: For inpatient care, the low scores

for inpatient responsiveness of Karnataka state in India

(41.4 on a scale of 100) would sit between the lowest

(Hebei) and second lowest (Guangdong) provinces in

China, while the highest score in India (Utta Pradesh,

50.6, would be comparable to China’s Hubei province

and not exceed the overall mean score in China. The low

scores for outpatient responsiveness for Karnataka in

India and Hebei province in China were both 34 out of

100, while the highest score in India (West Bengal, 51)

would rank third highest in China and closer to the over-

all Chinese mean score. Of course, it may also simply be

that the Chinese are hap- pier with the responsiveness of

the services provided in their systems than Indians.

Beyond a comparison to India, results from a number

of other countries were included in Tab l e 5 as a means

to put the Chinese results into perspective. Overall, re-

sponsiveness levels are quite low in the seven countries

included in these analyses. The Chinese inpatient system

did well in comparison to the other countries—and was

in the middle of ratings for its outpatient care system.

The difference in overall mean ratings for inpatient and

outpatient care was smallest in China (only 0.5 differ-

ence in the mean scores). Some striking contrasts were

seen when looking at responsiveness ratings from urban

and rural dwellers. A consistent trend of better respon-

siveness in urban areas was expected, but China and Viet

Nam rural dwellers rated both inpatient and outpatient

responsiveness better than their urban comrades. Review

of the results by different socio- demographic character-

istics would suggest minimal contribution of differences

in sex ratios, economic status or population structures

across the countries.

Differences in rates of health care utilization and un-

met need might also con tribute to these results, although

may be proxies for larger infrastructure and policy dif-

ferences. No clear patterns emerge from review of

national health accounts data and government or per

capita health spending [24]. Sri Lanka has low respon-

siveness scores, yet has a higher proportion of govern-

ment spending on health. Meanwhile, the Malaysian

government spends considerably more per capita on

health than China, but have similar levels of responsiv e-

ness. The distribution of public and private health care

provision should be examined in each country, as well as

training of health care professionals, as to reasons be-

hind differences in overall responsiveness. Better train-

ing and sensitization of professionals in the public and

private sectors to changes in burden of disease patterns

and the importance of therapy adherence for chronic

conditions (including disease management strategies that

incorporate lifestyle changes and continuity of health

care), will likely influence the responsiveness of these

health care providers. These may then translate into im-

proved health coverage and cost-effectiveness of inter-

ventions, both with economi c im pl i cations.

Differences in population health status may contribute

to these results across countries and would need to be

explored further. Mean health scores (on a scale of zero

to 100, where best health is 100) were highest in China

(81.2), Malaysia (80.1) and Viet Nam (83.3)—the other

countries’ mean scores were all below 75. The cause-

and-effect relationship is unclear: healthier people may

feel the health system is more responsive when they

come into contact with it; however, it may also be that

an intervention resulting in marked improvement in

health state for an episode of illness in less healthy peo-

ple may influence their experience and hence feel the

system has been responsive. In economic terms, the

concept of responsiveness my have the most currency

for chronic diseases which require regular and consistent

contact with a health care system over an extended

period of time to produce the greatest health gains in a

cost-effective manner. This would incorporate patient-

provider interactions but also public health and lifestyle

change efforts, to produce a responsive system which

induces improved patient adherence and outcomes. The

relationship between individual health status, health sys-

tem responsiveness and coverage along with sociode-

mographic characteristics of a population would be part

of an agenda for future research.

The results of this study suggest a need to improve

overall health systems responsiveness in both the inpa-

tient and outpatient settings, with particular government

attention to communication and quality of basic ameni-

ties as a means of improving the health systems per-

formance for current health needs. Unmet need for

health care among vulnerable populations (for example,

rural dwelling, older, lower socio-economic status) will

also need to be addressed as the results indicated sub-

stantial differences in responsiveness patterns. Older

P. Kowal et al. / Health 3 (2011) 638-646

645645

Chinese adults will increasingly be concerned about their

ability to pay for health care should they become ill in the

future, which will be exacerbated by recent changes to the

pension and health care systems [21,25-27], a more re-

sponsive health system may allay some of those fears.

5. ETHICAL REVIEW CONSIDE RATIONS

The WHO Ethical Review Board and the ethics com-

mittees of participating agencies in China and each

country approved this research.

6. ACKNOWLEDGEMENTS

The World Health Organization and the US National Institute on

Aging, Division of Behavioral and Social Research provided support

for the World Health Surveys.

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