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Dates: 2009-2014
Funding: Bill and Melinda Gates Foundation
Collaborators: Prof William Hsiao, Harvard University; Provincial Government of Ningxia; Ningxia Medical University; Fudan University; Shandong University.
Information: Winnie Yip
Project website: Ningxia Project

‘If we don’t change the systems, even the best tools may do no good, because they may never get to the people who need them.’ Bill Gates, April 2009

China has an emerging epidemic of multiple drug resistant tuberculosis (MDR-TB) with a quarter of the world’s cases.  The Chinese MDR-TB program, funded by the Gates Foundation, will adopt the latest innovative technology for TB control and standardize the approaches to diagnose and treat MDR-TB. However, there are barriers in the Chinese health care system that will inhibit the new technology to realize its full potential. Accordingly the Gates Foundation has also funded our program which seeks to address these barriers.

The primary goals of this program are to demonstrate how to enhance the effectiveness and efficiency of TB control by removing China’s health system barriers and to demonstrate a new long-term equitable and sustainable model for TB control.  This project will innovate on two principal interventions and demonstrate their feasibility and viability to enhance TB control:

1    Establish innovative incentive structure for CDC, hospitals, township health centers and practitioners to align the incentives with their proper roles and performance in TB control.  This intervention is to reduce delayed referrals, rendering unnecessary tests and prescription of unnecessary drugs and antibiotics, and retaining patients to earn higher income.

2    Introduce improved insurance benefit packages that would reduce the financial barriers for patients to seek TB diagnose and treatment.  This intervention is to reduce patients’ delays in seeking diagnosis, and interruption or incomplete treatment.

In addition, we will introduce companion interventions:
3    Deliver continuing education to providers on their roles and educate them on the correct performance of diagnostic and treatment of TB.
4    Educate the public to increase their awareness of TB and reduce stigma about TB and support patients to comply with treatment regimes, and educate patients on compliance.
5    Organize and engage communities in prevention and in monitoring of health providers’ performance in TB control programs.

This program is intended to impact on other areas besides TB, such as maternal and child health, vaccination and immunization and prevention and management of chronic diseases, in line with the overall goals of China’s current health care reform.  We are proposing a system change that will make the TB control program more effective. This same system change will improve the delivery of preventive and primary health services and people’s access to them.   Improved insurance benefit packages will cover all health conditions and thus reduce financial barriers to access care for all health conditions. Our proposed change in provider payment will create incentives for providers to improve performance in maternal and child health, immunization/vaccination and chronic disease management, as well as TB control and management. The change in incentives will also reduce unnecessary use of antibiotics and IV injections which will reduce drug resistance in the long run.

The program will be carried out and evaluated at experimental and control sites in rural areas of Ningxia province, China, with a population of close to two million. Townships are assigned by blocked randomisation to different interventions of provider payment methods, benefit package design and other quality-improving policies. Seven thousand households are interviewed in the baseline and each year afterwards in all.

For more information visit the Ningxia Project website.