Academic journal article Journal of Health Population and Nutrition

Financial Barrier against Access to Diagnostic Procedures among Enteric Fever Suspects in Highly-Endemic Areas of China

Academic journal article Journal of Health Population and Nutrition

Financial Barrier against Access to Diagnostic Procedures among Enteric Fever Suspects in Highly-Endemic Areas of China

Article excerpt


Nowadays, typhoid fever and paratyphoid (enteric fever in short) are rare in industrialized countries. However, they remain a serious health problem in the developing world. According to the best global estimates, at least 16 million new cases are diagnosed each year, with 600,000 deaths. Areas where the incidence reaches more than 100 cases per 100,000 people per year are considered to be endemic (1).

China has a relatively low incidence of enteric fever, ranging from two to five cases per 100,000 people per year. Yunnan, an underdeveloped province of southwestern China (gross domestic product [GDP] per capita of Yunnan was US$ 1,273 while the average GDP of China was US$ 2,280 in 2007) has the highest incidence of approximately 25 per 100,000 people per year in the nation (2). In 8-9 endemic counties of Yunnan, the rates rank the highest in China, reaching 100-375 per 100,000 people per year and contributing a total of 5,000 to 10,000 cases annually.

The absence of specific symptoms or signs makes the clinical diagnosis of this disease inaccurate. The definitive diagnosis of enteric fever depends on the isolation of Salmonella Typhi or S. Paratyphi from blood, bone-marrow, or a specific anatomical lesion (3). In practice, blood culture (haemoculture) is considered a minimum standard. Definitive diagnosis dictates adequate treatment of patients. Confirmed cases of enteric fever must be treated with efficacious antibiotic for at least 10 days to avoid relapse and carrier status. From a public-health point of view, accurate data are essential for priority setting, planning, and evaluation of various public-health measures. Proper diagnosis and treatment prevent carriers and promote public safety (4).

In developing countries, diagnoses of enteric fever are often made without cultures, especially in rural hospitals, due to lack of necessary facilities (5,6). From the Disease Information System of Yunnan, 40-50% of reported cases did not have blood culture done, although 80% of enteric fever cases were reported from hospitals at the county level or above where the test is available. The underlying cause of this problem is expected to be the health-financing system. Provincial price bureau fixes the hospital charge for haemoculture at RMB 80 (or approximately US$ 11) but the patient must pay this fee.

In 2007, the Yunnan province had 129 counties with a total population of 44.8 million, 70% of whom were farmers. There are three main health-insurance schemes in China: the New Rural Cooperative Medical Scheme (NRCMS), the Urban Worker Medical Insurance (UWMI), and private insurance. In rural areas, the NRCMS is most popular. It is a voluntary scheme with an annual premium of RMB 10 collected from each farmer participating and a subsidy of RMB 20 obtained from the provincial and central governments. This scheme began in 2005, and the coverage was 85% in 2007. The scheme does not cover any diagnostic procedures for outpatients (7). Persons in the same family share the same family reimbursement account, which has a fixed limit for outpatient services. The scheme usually reimburses 10% of outpatient drug-fees at the village clinics and township hospitals, with a maximum limit equal to the family premium. Reimbursement at the outpatient department of the county hospital is not possible. The UWMI, which involves a government subsidy added to a small amount of premium deducted from staff salary, covered only 7.8% of Yunnan's population in 2007 (8). This scheme reimburses a high percentage of the costs of diagnostic procedures and drugs. Private medical insurance is rare and usually does not have reimbursement for outpatient services. In practice, any reimbursement from the insurance will be directly paid to the hospital and deducted from the patient's bill.

Under the local circumstance that enteric fever is endemic and laboratory tests are available but not fully used, it is important to know the proportion of suspected patients not getting the proper test and to examine the extent of financial constraints of the patient's family and the effect of insurance on access to diagnostic procedures. …

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