Vol.3, No.10, 638-646 (2011)
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/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.
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-
Keywords: Ageing; Adult Health; Health;
Planning; Health Policy; Health Systems
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
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
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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.
2.1. 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
Communication Clear explanations
Time for questions
Autonomy Treatment information
Patient involvement
Confidentiality Talk privately
Confidentiality of reco r ds
Choice of Health Care
Provider Choice of provider
Quality of Basic
Amenities Cleanliness
Access to Support Family visit
External contact
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.
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
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
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
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
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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
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
A ge: 18-29
A ge: 80+
No educ at i on
12+ yrs educat i on
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
3.2. Mean Responsiveness Scores by
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
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
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
Prompt attention
Respectful Treatm ent
Commu nication
uality of Basic Amenit ies
Social Support
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
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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
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
P. Kowal et al. / Health 3 (2011) 638-646
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Table 5. Inpatient and outpatient system responsiveness mean scores by country and select socio-demographic characteristics.
China SE India SE Sri LankaSE MalaysiaSE NepalSE Philippines SE Viet NamSE
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
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
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
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
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
China SE India SE Sri LankaSE MalaysiaSE NepalSE Philippines SE Viet NamSE
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
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
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
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
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 countriesand 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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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.
The WHO Ethical Review Board and the ethics com-
mittees of participating agencies in China and each
country approved this research.
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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