Working Paper Series on MAKING INJECTIONS SAFE IN CHINA HOW MUCH WILL IT COST AND WHO WILL PAY? Paper No. 2004-11 QINGYUE MENG, JIANGBIN QU SUN, SHIXUE LI, YING BIAN CENTER FOR HEALTH MANAGEMENTAND POLICY SHANDONG UNIVERSITY JINAN, CHINA XINGZHU LIU ABTASSOCIATES INC. BETHESDA, MARYLAND, USA REKHAMENON THE WORLD BANK WASHINGTON DC, USA April 2004 CURRENCY EQUIVALENTS (Exchange Rate Effective April 1, 2004) Currency Unit = China Yuan Renminbi (CNY) 1 CNY = US$0.120824 US$1 = 8.27650 CNY FISCALYEAR January 1 ­ December 31 ABBREVIATIONSANDACRONYMS AD Auto-destruct AIDS Acquired Immune Deficiency Syndrome EPI Expanded Program of Immunization FFS Fee-for-Service GAVI Global Alliance for Vaccines and Immunization GDP Gross Domestic Product GIS Government Insurance Scheme HBV Hepatitis B Vaccine HCV Hepatitis C Virus Infection HIV Human Immunodeficiency Virus JE Japanese Encephalitis JICA Japan International Cooperation Agency MOH Ministry of Health SARS Severe Acute Respiratory Syndrome SSB State Statistics Bureau STIs Sexually Transmitted Infections TB Tuberculosis TST Time, Steam, Temperature UNDP United Nations Development Programme WHO World Health Organization WTO World Trade Organization Making Injections Safe in China: How Much Will It Cost and Who Will Pay? ACKNOWLEDGEMENTS This study was funded by a Dutch Trust Fund from the Public Health Thematic group of the World Bank. The task manager for the study is Rekha Menon and the sector manager is Fadia Saadah. The peer reviewers are Logan Brenzel, HDHNE and Enis Baris, ECSHD. Editorial assistance was provided by Brandel Bravo Frances. Administrative assistance was provided by Sabrina Terry. The research team would like to acknowledge the assistance of the following persons without whom the study could not have been conducted. Lisa Lee from the World Health Organization's (WHO) Beijing Office helped develop the study design and provided useful references, for which we are grateful. We wish to express our appreciation to Yu Jingjin, Cui Gang and Lei Zhenglong from the Ministry of Health's Department of Disease Control for their support in coordinating the field-work, developing the study design, and reviewing the draft report. We would also like to acknowledge Feng Zijian, Wang Xiaojun, Hao Lixin, Li Yixing, Guo Biao, and Craig Shapiro from the National Immunization Program and China's Global Alliance for Vaccination and Immunization (GAVI) program for their contributions to this study. We thank Shandong and Shaanxi Provincial Departments of Health for their assistance in coordinating the field-work. We thank Logan Brenzel from the World Bank for her comments on the study design and draft of the technical report. Lastly, we gratefully acknowledge Yu Jingbo, Lin Yanjun, Li Shunping, Zhang Weiyan, Sun Xiaojie and Ge Renwei from Shandong University for their work in data collectionanalysis and literature review. Making Injections Safe in China: How Much Will It Cost and Who Will Pay? TABLE OF CONTENTS Executive Summary...................................................................................................iii 1. Introduction.....................................................................................................................1 2. The Study Methodology .................................................................................................2 2.1 Study Sites.............................................................................................................2 2.2 Sources of Data.....................................................................................................3 2.3 Sampling and Data Collection Methodology........................................................3 2.4 Information Collected ...........................................................................................5 2.5 Methodology and Data Limitations ......................................................................5 3. Findings ..........................................................................................................................6 3.1 Immunization Program Financing........................................................................6 3.2 The Overall Situation of Injection Safety..............................................................12 3.3 Current Utilization and Cost of Syringes..............................................................16 3.4 Costs of Ensuring Adequate Supply of Disposable and AD Syringes ...................22 3.5 Cost of Disposal Methods .....................................................................................27 3.6 Viability of Disposal Methods...............................................................................30 4. Discussion.......................................................................................................................33 5. Policy Recommendation.................................................................................................34 References .............................................................................................................................36 Figures Figure 3.1: Apparatus used for Sterilizing Reusable Injections Materials........................14 Figure 3.2: Containers for Containing Medical Wastes in a Villages Clinic....................15 Figure 3.3: The Stove used for Burning Medical Wastes .................................................16 Tables Table 2.1: Major Indicators for the Counties Studied.........................................................3 Table 2.2: Samples for Investigations in the Two Provinces..............................................4 Table 3.1: Allocation of Public Funding for Disease Control Centers ...............................8 Table 3.2: Collection and Distribution of Revenues from User Charges for......................10 Immunization Services Table 3.3: Proportions of Syringes used for Immunization and Therapeutic Services.......13 Table 3.4: Methods of Disinfecting Reusable (Glass) Syringes .........................................13 Table 3.5: Methods of Disposing of Disposable Syringes..................................................15 Table 3.6: Number of Injections for the Immunization Programs ......................................17 Table 3.7: Estimated Volume of Service and Injection Ratio in China..............................18 Table 3.8: Estimated Volume of Service and Injection Ratio in Shandong........................18 Table 3.9: Estimated Volume of Service and Injection Ratio in Shaanxi...........................18 Table 3.10: Estimated Number of Therapeutic Injections ....................................................20 i Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.11: Estimated Number of Immunization Injections.................................................20 Table 3.12: Cost of Syringes for Therapeutic Injections ......................................................21 Table 3.13: Cost of Syringes for Immunization Injections...................................................21 Table 3.14: Projected Immunization Coverage for Advanced Provinces .............................23 Table 3.15: Projected Immunization Coverage for Mid-income Provinces..........................23 Table 3.16: Projected Immunization Coverage for Under-developed Provinces..................23 Table 3.17: Projected Numbers of Injections for Defined Immunization Programs.............24 Table 3.18: Projected Cost of Injections using Disposable Syringes for Defined ................24 Immunization Programs Table 3.19: Projected Cost of Injections using AD Syringes for Defined ............................25 Immunization Programs Table 3.20 Projected Incremental Cost of Injections using AD Syringes Replacing ..........25 Disposable Syringes for Defined Immunization Programs Table 3.21: Projected Incremental Cost of AD Syringes Replacing Disposal......................26 Syringes for Defined Immunization Programs by Province Table 3.22: Estimates of Government Budgets Allocated to Purchasing of AD ..................27 Syringes and Costs as a Proportion of Health Budget in Western Provinces Table 3.23: Cost of Disinfection and Destruction of Disposable Syringes...........................28 Table 3.24: Cost of Burning Disposable Syringes................................................................29 Table 3.25: Cost of Safety Boxes for Disposable Syringes per Year ...................................29 Table 3.26: Cost of Combined Methods for Disposal of Syringes .......................................29 Table 3.27: Average Points Given to each Disposal Practice/Component ...........................30 Table 3.28: Feasibility of Combined Methods for Disposal of Used Injections Materials...32 Table 3.29: Costs of Preferred Methods of Disposal of Used Injection Materials ...............32 in the Study Counties Annexes Annex 1: Question Guide for Interviewing Key Informants.............................................A.1 Annex 2: Review of EPI Health Insurance System...........................................................A.2 Annex 3: Documented Situation of Injection Safety.........................................................A.3 Annex 4 Reported and Actual Coverage of Immunization Programs ..............................A.4 Annex 5: Projected Numbers of Children, Injections and Costs.......................................A.5 Annex 6: List of Chinese Experts Involved in the Study ..................................................A.6 ii Making Injections Safe in China: How Much Will It Cost and Who Will Pay? EXECUTIVE SUMMARY An Overview of the Problem While the use of disposable syringes has risen dramatically over the past decade, Injection safety is a major concern in most of the increase has occurred in urban China and a high priority for the Ministry areas, where over 75% of immunizations of Health. The unsafe use and are provided with disposable syringes. In inappropriate disposal of injection rural areas, especially in the western materials place patients, health care provinces, disposable syringes are used in workers, and entire communities at only 20% of immunizations. This figure is increased risk for infection and injury. even lower for therapeutic injections, Annually, between 8 to 16 million which account for more than 90% of all Hepatitis B infections occur around the injections. world due to unsafe injection practices. The number of Hepatitis C infections each China's government aims to achieve safe year due to unsafe injections is between injection practices in EPI by the year 2005. 2.3 to 4.7 million worldwide. One in It has proposed that by the end of 2004 all fourteen people with Human immunization injections--in both urban Immunodeficiency Virus (HIV) contracted and rural areas--be given by approved the virus through unsafe injections. auto-destruct (AD) syringes. In 1996, the year that the Chinese Since the initiation of economic reforms in government launched its National the mid-1980s, user fees have been Expanded Program of Immunization (EPI) increasingly relied on to finance China's Safe Injection Plan for 1997-2000, only public health programs. Concomitantly, 30% of all injections were provided the percentage of public funding covering according to the national injection total operating costs for preventive care standard of one sterile syringe and one services has dropped dramatically. sterile needle for each injection. The Moreover, financial decentralization in the Government of China, with assistance health sector has had the unintended from its development partners, has made consequence of widening the gap between great strides in improving injection safety. public health programs serving rich and The Ministry of Health has issued poor, particularly rural areas. regulations regarding the safe disposal of medical waste, including injection Improving injection safety is contingent materials for both immunization and other upon many factors, not least of which is health (therapeutic) services. However, financing. In the short term, before health even today, use of non-sterile syringes, benefits can accrue, increasing safety re-use of syringes, and unsafe disposal of means increasing costs--whether to the syringes is not uncommon. In China's government, the health care user or both. Yunnan Province, 50 to 500 HIV cases In a rapidly changing economy and health result each year from unsafe injections. care system such as China's, cost Likewise, inappropriate disposal of estimations are sorely needed if the injection materials has harmed many government is to develop practical plans individuals, particularly children. About for financing and sustaining safe injection 65% of eye injuries in China's rural areas and disposal programs. Consequently, a have been caused by improperly disposed study was designed, the results of which needles. In 2001, 15.7% of health workers are the basis for the recommendations that in Wulong of Chongqing were injured due conclude this Executive Summary. to the improper destruction of injection needles. iii Making Injections Safe in China: How Much Will It Cost and Who Will Pay? The Study costs related to immunization. The cost of obtaining a vaccination that is not part of The study, carried out in 2003, had the the EPI program is borne entirely by the following objectives: user. Most of the user charge for non-EPI vaccinations goes toward labor costs, with (i) To review recent changes in injection materials accounting for only a immunization financing and small portion of the service fee. identify existing problems; (ii) To estimate the number of Health facilities reported that they did not injections and type of syringe have access to a specific government fund used (reusable vs. disposable) for ensuring injection safety and safe by service type disposal of injection material. In addition, (immunizations vs. curative no specific instructions on the use of user injections) and level of fees for the safe disposal of used injection administration (village, material exist. township, county, and city). Under the current system, health care (iii) To project the costs of providers have no financial incentive to ensuring an adequate supply adopt safe injection practices and practice of disposable and AD syringes; proper disposal of injection material. and, Without public financial support and the (iv) To estimate the costs and promulgation of strict regulations, health investigate the feasibility of care providers tend to focus on keeping alternative strategies of down the costs of purchasing, sterilizing injection material disposal. and disposing of injection materials--at the expense of safety. The study methodology relied on a combination of literature review, key The Number, Type, and Safety of Injections informant interviews, and facility-based surveys. The interviews and surveys were Injections in China totaled an estimated conducted in the two study areas of 2.5 billion in 2003, with therapeutic Shandong and Shaanxi provinces. injections accounting for 94%. The ratio Shandong, located in the east, is China's of therapeutic injections to immunization second largest province, whereas Shaanxi injections was 15.7 to 1. Over half (58%) is a smaller and less developed western of all therapeutic injections provided in province. In addition to the 216 interviews 2003 were administered by village clinics. performed in the two study provinces, The research team estimates the number of officers from relevant national institutions therapeutic/curative injections per were also interviewed. A total of 95 outpatient encounter to be 0.46 at village facilities representing all four clinics, 0.33 at township health centers, administrative levels (village, township, 0.19 at county hospitals, and 0.12 at city county and city) were surveyed in the two hospitals. The number of therapeutic designated provinces. injections per inpatient day is estimated to be 0.21 at township health centers, 0.54 at The Study Findings county hospitals, and 0.66 at city hospitals. Paying for Safe Injections In the poorer province, Shaanxi, nearly a The research revealed that immunization third (31.2%) of immunizations provided services in China are mainly financed through village clinics were given with through user service fees and EPI reusable syringes. Sterilizing conditions prepayment schemes. User charges cover for reusable injection materials were labor costs associated with immunizations, generally unsatisfactory, especially in poor injection materials, and other operational counties. iv Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Current and Future Costs of Injection In Shandong, township, county, and city Material1 health facilities indicated a preference for a combination of disinfection/destruction The cost of purchasing syringes for and recycling. In Shaanxi, township health therapeutic injections delivered in 2003 facilities, when given a choice, opted for a would have been 625.4 million yuan. combination of safety boxes and burning. Syringes for immunizations would have County and city health facilities, however, required an expenditure of 35.6 million favored a system of disinfection/ yuan. destruction and recycling, which is free for health facilities in Shaanxi's townships, In order to provide the seven counties and cities. recommended immunizations (BCG, DTP, Measles, DT, JE, Hepatitis B, and The estimated costs of disposing of used Meningococcal) by either disposable injection material vary by administrative injection material or AD syringes in 2006, level, study province and method or China would need to expend either an combination of methods employed. In additional 65.4 million yuan for Shandong, the larger province with higher disposables, or 147.6 million yuan if only per capita GDP, village clinics need to AD syringes are to be used. The spend anywhere from 119 to 260 yuan a incremental cost of replacing disposable year. Disposal costs for township health syringes with AD syringes in 2006 would centers range from 1,988 to 3,150 yuan. be 82.2 million, 10.2 million yuan of For county hospitals, costs run between which would be for immunizing against 5,447 yuan and 16,754 yuan. City Hepatitis B using AD syringes. hospitals can dispose of used injection material at a cost of 79,031 to 141,469 If the government were to cover 70% of yuan. In Shaanxi, village clinics must the cost of AD syringes in each of the 12 budget 32 to 94 yuan to dispose of western provinces, it would take anywhere injection material. Township health centers from 0.09% to 0.49% of provincial health require 83 to 600 yuan. County hospitals budgets to do so, or 0.72% to 3.38% of the need to expend 1,700 to 3,666 yuan, funds budgeted for disease control and whereas for city hospitals the amounts are prevention. 47,578 to 120,078 yuan. Methods and Costs of Disposing of Used If the government were to cover 70% of Injection Material the cost of disposing of used injection material, it would amount to less than None of the recommended 100,000 yuan per county in Shandong, and technologies--safety boxes, incinerators, approximately 20,000 yuan per county in or Time, Steam, Temperature (TST) spot Shaanxi. indicators--were found at any of the study sites. Policy Recommendations Village clinics rarely disinfect and destroy Correct Financial Incentives for Public disposable syringes, as required, before Health Care Providers. Current financial burning and burying them. In both incentives lead public health facilities to provinces, the heads of village clinics neglect less profitable preventive health cited the combination of burning and care services, in general, and injection burial as their favorite disposal system, safety in particular. In order to address this most likely because, for them, it is the problem, the government should consider: least expensive method. · Separate accounting systems for 1 The study sites may not be sufficiently free immunization services and representative of all provinces in the country. for-profit preventive care to assure Data and methodology limitations are appropriate use of public monies. discussed in section 2.5. The Government needs to clearly v Making Injections Safe in China: How Much Will It Cost and Who Will Pay? define the responsibility of public · Redirecting financial resources health care providers and regulate away from curative services and the allocation of public funds. toward public health care; Most importantly, EPI funds should not be used for the · Increasing public funds for safe provision of for-profit health care. injection programs; and · Establishing a specific fund for · Requiring central and local the purchase, distribution, and safe governments to share the cost of disposal of injection material for replacing older technologies with immunization services. If new ones. carefully regulated, such a fund would motivate health care Develop and Institute Protocols for providers to properly use and Disposal of Used Injection Materials. dispose of injection materials. Methods for disposing of used injection materials vary by setting. Cost-effective · Increasing subsidies to poorer methods acceptable to immunization areas to ensure equal access to providers in different localities or at new, safer injection technologies different administrative levels should be and encourage the adoption and developed. Based on cost and preferences continued practice of safe expressed by those interviewed, the injection and disposal practices. research team suggests: Reassess User Fees. The impact of user · At village clinics, burning and fees on the behavior of health care burial should be the norm. providers and users of immunization Recycling, too, should be services is not yet well understood. On the considered provided it is free of one hand, increased revenue from user charge to village clinics, as is the fees could motivate health care providers case for higher-level facilities. to expand and improve immunization services. On the other hand, higher fees · At township, county, and city may dissuade people, particularly the poor, health facilities, disinfection/ from seeking immunization services. The destruction and recycling should policy guiding user fees in the public become standard procedure. health sector should be revisited to examine its possible negative impact on Strengthen Training Programs for Safe utilization of immunization programs. Injection Practice. Behavior of injection providers is one of the crucial Ensure the Supply of Safe Injection determinants for injection safety. Training Materials. The government needs to play a programs should be well organized and leading role in the organization and sufficiently offered to health providers to provision of safe injection materials. increase their awareness of risks of the Compared to total health expenditures and unsafe injection and their skills of using the resources allocated to tertiary hospital appropriate system for sterilization and services, the cost of replacing current destruction of used injection material. injection materials is minimal. The Education to the general public is also government could make safer injection required to increase awareness of the risks practices financially feasible by: of unsafe injections for the communities. vi Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 1. Introduction Among people with HIV, 1 in 14 became infected through unsafe injections [3, 6]. It Injection safety is a major concern in is estimated that 50 to 500 HIV positive China and a high priority for its Ministry cases in Yunnan Province each year can of Health (MOH). In 2002 alone, about 3 be attributed to unsafe injections [7]. billion injections were provided for both immunization programs and therapeutic Inappropriate disposal of injection services in China [1]. While use of materials has also caused serious harm to disposable syringes has increased many communities, especially to children. dramatically over the last decade, there is About 65% of eye injuries in rural areas of still much variation in use-- both across China are caused by improperly disposed provinces and between urban and rural needles [8]. In 2001, 15.7% of health areas. In urban areas, the coverage of workers in Wulong of Chongqing city disposable syringes for immunization were injured due to the improper services (immunizations account for 5% to destruction of injection needles [9]. 10% of all injections) is over 75% on average, while in rural areas, especially in The Government of China, with the western provinces, use of such syringes assistance of its development partners, has only accounts for about 20% of total made major strides in improving injection syringe utilization [2]. For therapeutic safety. In 1996, the government issued the injections, the coverage of disposable National EPI Safe Injection Plan of Action syringes is even lower [2]. 1997-2000, which promised to increase coverage of safe injections for This is a major improvement given that in immunization programs. The Ministry of 1996 only 30% of all injections were Health has also issued regulations on the provided according to the national safe disposal of medical waste, including injection standard of one sterilized syringe disposal of injection materials for both and one sterilized needle for each injection immunization and therapeutic services. [3]. However even today, use of However, as indicated above, several non-sterile syringes, re-use of syringes and problems still need to be addressed. unsafe disposable of syringes is not uncommon. In 2000, in the western China's government has implemented its provinces of Shanxi, Shaanxi, Qinghai, action plan with the aim of ensuring safe and Ningxia, 28.1% of immunization injection practices in EPI by the year injections were provided with shared 2005. In the national plan, it was proposed needles [4]. In these same provinces, that by the end of 2004 all immunization nearly 20% of disposable syringes were injections--in both urban and rural thrown away after use rather than being areas-- should be given by approved auto disinfected and destroyed [4]. In 2001, in destruct (AD) syringes. In order to achieve the Puyang Prefecture of Henan Province, these aims, each province has been asked 75% of disposable syringes were thrown to develop an implementation plan for away in rural health facilities without any transitioning to AD syringes. These plans appropriate disposal measures being taken must address: (i) disposal, including use of [5]. safety boxes, collection systems, and methods for destruction; (ii) supply and The unsafe use and inappropriate disposal logistics; (iii) monitoring and supervision; of injection materials increase the risk of and (iv) procurement and budgeting. patients, health care workers, and the community at large contracting hepatitis B Ensuring injection safety is determined by and C, as well at the Human a number of factors. One important factor Immunodeficiency Virus (HIV). About 8 in a rapidly changing health care system to 16 million hepatitis B and 2.3 to 4.7 such as China's, is the mechanism for million hepatitis C infections result every financing and sustaining safe injection year from unsafe injections worldwide. programs. The government needs cost 1 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? estimates in order to develop practical costs associated with introducing new plans for financing and sustaining these technologies. programs. Shandong is the second largest province in The study attempts to answer three China, with a population of 90 million in questions: How are immunization services 2001. Located in the east, the province is currently being financed? What are the made up of 17 prefectures and 135 estimated current and future costs of counties. Shandong has a relatively strong supplying disposable and AD syringes? and rapidly developing economy, with a And, what are the costs of disposing of per capita GDP in 2001 of 8,673 yuan used injection materials? (US$1,050). Economic development varies widely, however, across counties. The specific objectives of the study were: Shandong's health system includes a network of 400 hospitals at the county · To review recent changes in level and above (98% public and 2% immunization financing and private), 10,500 clinics (half identify existing problems; public/collective and half private), and 170 anti-epidemic stations (public). · To estimate the number of Tuberculosis (TB) and Sexually injections and type of syringe used Transmitted Infections (STIs) are the (reusable vs. disposable) by major public health problems. service type (immunizations vs. curative injections) and level of In comparison, Shaanxi Province is an administration (village, township, economically underdeveloped province, county, and city). located in the west of China. Shaanxi has a population of 36 million with a per capita · To project the costs of ensuring an GDP in 2001 of 4,549 yuan (US$530). adequate supply of disposable and There are 91 hospitals at the county level AD syringes; and and above, 80 anti-epidemic stations, 2,026 township hospitals and 28,530 · To estimate the costs and village clinics, with a public-private mix investigate the feasibility of similar to Shandong's health system. alternative strategies of injection Hepatitis B and TB are the chief public material disposal. health problems in this province. 2. The Study Methodology Table 2.1 presents some indicators for the counties in Shandong and Shaanxi that 2.1 Study Sites were selected for inclusion in the study. Average per capita net income for the The investigators selected two provinces, three Shandong counties closely Shandong and Shaanxi, as study sites approximates the average for the province based on their discussions with Ministry of as a whole. The two Shaanxi counties, Health (MOH) officials and officers from which are recognized as among China's the National Immunization Program and poorest, reflect the less developed status of the EPI program (Hepatitis B vaccination) the province. in Shaanxi, which receives support from a GAVI project emphasizing the importance According to the national population of systemic strategies for safe injections. census in 2000, 74% of population were residing in rural areas and 36% were in GAVI/Vaccine Fund to China is for urban areas. In 2002, per capita GDP was US$15.9 million in safe injection 7972 yuan for the country and per capita commodity assistance, and US$21.9 net income for rural people was 2476 yuan. million in vaccines (Hepatitis B mono Reported immunization overage for does), plus one-time grant to cover the EPI programs was 98% in 2001. 2 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 2.1: Major Indicators for the Counties Studied, 2002 Indicators Shandong Shaanxi Sishui Weishan Zhoucheng Xunyi Bin Economic development Population (10,000) 59.5 68.5 110 26.8 31.2 % of rural (%) 11.0 17.6 36.3 95.0 95.0 % of urban (%) 89.0 82.4 63.7 5.0 5.0 No. of township 12 14 17 17 20 No. of village 574 580 883 280 325 Per capita GDP (yuan) 7200 6276 14319 1732 1958 Per capita net income (yuan) 2454 3700 3313 1324 1498 Gov't revenue (million) 240 330 712 41 52 Per capita Gov't revenue (yuan) 403 482 650 153 167 Health care system No. of village clinics 360 742 691 243 298 No. of township health centers 12 14 20 14 16 No. of county health facilities 8 5 7 5 4 Immunization coverage of EPI Reported coverage (%) 98 98 98 95 95 Estimated coverage (%) 85 85 95 75 75 However, there is no country-wide data 2.3 Sampling and Data Collection indicating the actual immunization Methodology coverage. Key words used for literature searches 2.2 Sources of Data included: immunization, disposable syringes, AD syringes, financing, costs, The main sources of information for the user fees, immunization coverage, and study were reviews of existing literature injection safety. Policy documents were and reports, key informant interviews, and collected from national and provincial results from a facility-based survey. authorities including health departments Documents reviewed include policy and disease control institutions. The WHO documents, World Bank and World Health Beijing Office provided most of the Organization (WHO) mission reports, mission reports. A Chinese literature statistical reports, and published literature. search was conducted using the Qinghua Key informant interviews were used to University and Weipu databases, which are explore problems and challenges relevant the largest in China. to financing immunization programs, including injection safety measures, and to Interviews were conducted in the two assess feasibility of strategies for provinces of Shandong and Shaanxi. The disposing of used injection materials. A study sites included the capital cities facility-based survey was conducted for (Jinan in Shandong and Xi'an in Shaanxi) information on financing immunization of each province, two counties in Shaanxi injections and disposal of injection Province (Xunyi County and Bin County), materials, for estimating the number and and three counties in Shandong Province proportion of immunization injections, and (Sishui County, Weishan County, and for information on methods currently used Zhoucheng County). For each of the to dispose of used injection materials. counties in Shaanxi, two townships and 3 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? three villages in each township were individuals selected for interview. selected. For each of Shandong's three counties, two townships and five villages For the facility-based survey, a total of 95 in each township were selected. Local facilities at four levels in the two officials and experts, together with the provinces were selected. In the capital investigators, decided jointly on the cities of Jinan and Xi'an, the biggest selection of the counties, townships, and provincial hospital and biggest municipal villages, based on the coverage of hospital in each were selected from among disposable syringes and the level of 10 such hospitals per city. In each of the economic development. Interviews were five selected counties, the largest general carried out in each province with hospital was surveyed. All the health provincial and county officers responsible centers in each of the selected townships for safe injection management and were studied. About 29% of village clinics regulation, as well as with the health in Shandong, and 20% of village clinics in managers and heads of each health facility Shaanxi, within the selected townships selected (Table 2.2). Officers from were surveyed. All clinic heads were relevant national institutions were also interviewed (each village clinic had 2-3 selected for interviews. The investigators health workers). Institutional records were developed a question or topic guide for the main source of data. The survey was these interviews (see Annex 1) and conducted in all the facilities selected for conducted them at the workplaces of those study. Table 2.2: Samples for Investigations in the Two Provinces Study Sites No. of No. of No. of Facilities Interviewees on Interviewees on Current Costs and Feasible Immunization Methods of Financing and Disposal Problems (Objective 1) (Objective 4) City: 2 in Shaanxi; 2 in 4 tertiary 9 officers 5 hospital managers Shandong hospitals County: 2 in Shaanxi; 5 county 8 officers and 10 hospital 3 in Shandong hospitals CDC managers managers Township: 4 in 10 health 16 health managers 16 health managers Shaanxi; 6 in centers Shandong Village: 12 in Shaanxi; 76 clinics 76 heads of clinics 76 heads of clinics 64 in Shandong Total 95 109 107 4 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 2.4 Information Collected and needles, by level of administration; and Five categories of information were collected, either through direct · Estimated costs of alternative investigation or literature review: methods recommended for safe disposal of syringes and needles. Financing of Immunization Programs Viability of Methods for Disposal of · Changes in immunization Syringes and Needles financing mechanism; The viability of each disposal method was · Coverage and arrangement of EPI examined by taking into consideration the prepayment scheme; following five factors: · Percentage of immunization · Costs; program costs financed by public funding, user fees or other; · Community safety; · Distribution of expenditures on · Health care provider safety; immunization services by injection materials and labor and · Environmental regulations; and other; and · Acceptability to health care · Difficulties in sustaining providers. immunization programs financially. 2.5 Methodology and Data Limitations Numbers of Injections At least three limitations have been · Number of immunization identified in this study. injections by disposable and reusable syringes, and by level of (i) The parameters for projecting the administration; and number of injections and costs of syringes, derived from the study sites, may be · Number of therapeutic injections insufficiently representative for by disposable and reusable generalizing to the country as a whole. syringes, and by level of Estimates used to project the number of administration. injections and the costs of syringes included: the number of injections per Costs of Syringes outpatient encounter and per inpatient day, the proportion of disposable versus · Cost of syringes for immunization reusable syringes, and the unit price of services; syringes. In poor areas, the number of injections per outpatient encounter and per · Cost of syringes for therapeutic inpatient day may be lower than average services; and because inhabitants are less able to afford health care services. Similarly, the · Future costs for ensuring adequate proportion used of more costly disposable supply of disposable and AD syringes and the unit price of syringes may syringes. be lower than average. As mentioned previously, the two counties in Shaanxi are Costs of Disposal of Syringes and Needles among the poorest in the country. In Shandong, two of the three counties · Cost of various methods currently studied -- Zhoucheng being the exception being used for disposal of syringes -- are less developed on average than 5 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? other counties in that province. to extrapolate the standard required costs, Consequently, the estimates for the if the procedures used for disposal are not number of injections and the costs of standard ones. The estimates are useful in disposable syringes for the country, in that they reveal the least costly methods of general, and economically advanced supporting the current disposal system. provinces, in particular, may have been under estimated. A similar problem arose 3. Findings when estimating costs for disposing of used injection materials. The costs of 3.1 Immunization Program disposal may also be under estimated Financing given that supplies and labor are less costly in poor areas, and that incinerators In this section, recent changes in health were not found at the study sites. One way care financing are summarized. The to overcome these problems would be to mechanisms for financing immunization expand the study to include more services at study sites are described, representative sites. Another option would including a short review of the EPI be to adjust the results according to some prepayment scheme. The problems estimates arrived at in future work. associated with immunization financing, and suggestions offered by study (ii) The drop outs--children who do not interviewees for redressing them are also complete a vaccination regimen-- and presented. overprovision of injections were not accurately estimated. Even if we were to 3.1.1 Major Changes in Health Care redefine immunization coverage (see Financing Section 3.3.1) for the purposes of this study, trying to reflect the numbers of In recent years, China's health care injections provided to children without financing system has undergone several completing the whole standard changes. Prior to the economic reform immunization procedure and the numbers initiated in the 1980's, health care was of children receiving too many financed for nearly 90% of the rural immunizations, we still would not be able population by a community-based to guarantee the accuracy of the estimates cooperative medical system supported by used for immunization coverage because the government and the collective of a lack of empirical data. Given that it's economy. Pre-payment schemes were not realistic to get the data from a underwritten by pooling together village population-based survey, one way of communal funds, member contributions, possibly improving the data's reliability and government subsidies. The urban would be to ask for more comments from population, on the other hand, was covered a wide range of immunization officers and mainly by government health insurance experts. Any changes in immunization and labor health insurance plans. Public coverage can be used for generating new hospitals and clinics were primarily projections with the existing software funded through government budgets, and program. the costs of medical care were highly subsidized. With economic reform, which (iii) This study only estimates actual costs led to the collapse of the collective of disposal of used injection materials; it economy, the cooperative medical system does not establish standard costs. Disposal in most rural areas was dismantled. As a methods at study sites varied and were result, about 90% of people in rural areas limited by the level of the health facility; now pay the full cost of their own medical estimates of actual costs were made for care [10]. In urban areas, the rapid rise in available methods only. For example, medical costs has made government and because village clinics used burial and labor health insurance plans unsustainable burning only, we were not able to estimate [11, 12]. The percentage of public hospital costs of other methods at village clinics. In costs covered by government budgets has addition, the actual costs may not be used decreased. User fees, which are mainly 6 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? out-of-pocket-payments by households, strengthen the leadership capacity of local and earnings from the sale of medicine, health facilities and encourage local have become the major source of finance support for developing the community for public hospitals, accounting for about health sector, it has, in this case, led to 90% of hospital revenues. escalating medical costs and diminished access to medical services, especially for User fees for public health programs, the rural poor. The research indicates that including preventive care services, were the rural health care system in poor areas, introduced in the mid-1980s to meet the including the sustainability of the gap between costs and government budget three-tier system, and promotion of health allocations. In 2000, over 50% of the technologies has been negatively affected funding for disease control and prevention by financial decentralization [17]. programs came from user charges [13]. Localities in poor areas, without support Out-of-pocket payments made by from richer areas or cross subsidies, have individuals constitute more than half of been facing difficulties in financing total health expenditures since 1995 [14]. essential health services. A study that examined the relationship between In 1995, about 226 billion yuan were spent financial decentralization and the in China's health sector, accounting for performance of tuberculosis control 3.9% of gross domestic products (GDP) programs found that tuberculosis programs [15]. A breakdown by source of payment in poorer counties performed more poorly reveals that 17% came from the than those in wealthier counties [18]. The government, 33% from employers, and chief problem related to decentralization is 50% from out-of-pocket payments by that low-level health facilities in poor individuals. About 6.8% of total health areas are not adequately supported under expenditures went to public health the current fiscal system because a system programs [15]. By 2001, national health of transferring payments has not been expenditure had increased to 515 billion effectively established. The decision- yuan, accounting for 5.4% of GDP [16]. makers are proposing strategies for Of total health expenditures, 15.6% came addressing these problems, either by from government, 24.0% from employers, re-centralizing the rural health care system and 60.4% from out-of-pocket payments. or strengthening the transfer payment About 5.3% of total health expenditures in system. 2001 were for public health programs. Between 1995 and 2001, the proportion of The study uncovered large variation in the health expenditures attributable to financial capability of local governments out-of-pocket payments increased and the to support social development programs proportion of health expenditures for between Shandong and Shaanxi (see public health programs decreased. Table 2.1). Per capita government revenue in the selected counties of Shandong was Decentralization in health care financing, more than double that of the counties of also initiated in the mid-1980s, has played Shaanxi. In addition, the net income of a leading role in driving health sector Shandong residents was much higher than reforms in China. Health funding and among inhabitants of Shaanxi. Table 3.1 management responsibilities have been shows the allocation of public funding for transferred from central and provincial disease control centers by selected governments to county and township provinces. governments. While decentralization can 7 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.1: Allocation of Public Funding for Disease Control Centers, 1999 Provinces Expenditures Public Public Public (10,000 Funding Funding as Funding yuan) (10,000 yuan) % of Total per Capita Expenditure (yuan) Beijing 29034 6243 21.50 4.63 Shanghai 37692 14387 38.17 8.77 Liaoning 43984 16847 38.30 4.03 Jiangsu 55338 20057 36.24 2.75 Shandong 56985 20554 36.07 2.28 Hubei 42755 13091 30.62 2.20 Anhui 22321 11934 53.46 2.02 Henan 37251 15110 40.56 1.66 Sichuang 37021 14699 39.70 1.78 Guizhou 8845 6355 71.84 1.80 Shaanxi 11683 6192 53.00 1.72 Gansu 9023 6262 69.40 2.49 Qinghai 3345 2383 71.25 4.94 Data Source: Ministry of Health, Health Accounting Report, 2000. Three major health financing reforms are Basic curative services and essential drugs being proposed or implemented at present were provided in the service package. in China. First, a rural health insurance Third, funding policy for public heath system is being proposed. Based on the programs is being reoriented. This reform experience of the rural medical insurance was initiated largely due to the outbreak of system, the government is planning to SARS in the first half of 2003. Rural establish a new health insurance system health infrastructures for delivering public which would include coverage for health programs will be strengthened by catastrophic diseases and protect against government support. In urban areas, the financial risks of disease. As of 2003, specific departments for dealing with the central government allocates a 10-yuan infectious diseases within hospitals are specific subsidy for poor people, and the being set up, and municipal hospitals local government allocates a 10-yuan specializing in infections disease are being matching fund per person per year for updated. A total of 11 billion yuan have initiating and sustaining the establishment been budgeted for those activities [22]. of the insurance scheme [19]. In wealthy areas, the local government will be 3.1.2 Immunization Program Financing responsible for providing part of the financial support for operating the scheme. Since their introduction in the mid-1980s, Second, urban health insurance reform is user fees have been increasingly relied on already under way. Employee-based urban for covering the cost of immunization health insurance, combining government services, including EPI programs. Even health insurance and labor health though vaccines are still free for the users insurance schemes, was widely established of the EPI program, fees are charged to by the end of 2002, with about 940 million cover the costs of labor and injection employees in urban areas covered [20]. materials. There are two collection Premiums for this insurance scheme call mechanisms: fee-for-service, where users for 8% of total salaries -- 2% contributed are charged each time when they receive a by employers and 6% by employees [21]. vaccination; and the EPI prepayment 8 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? scheme, where users pay premiums for a allocated to county, township, and defined package of immunization services. village health institutions based on proportions agreed upon by The EPI prepayment scheme was initiated the relevant parties; in China in 1984, and its coverage has expanded to most of the country since then. · Use of the premiums--the Under the EPI prepayment scheme health premiums collected were spent on care providers (insurers) established a set a range of costs related to package of immunization services, as well immunization services, including as a compensation plan in case of labor, injection materials, and inoculation accident, immunization failure, compensation; and or disability and death due to any of the diseases for which immunizations were · Compensation--the amount of administered. By defining the services and compensation varied depending compensating users for failings in service on the location and type of delivery, the EPI prepayment scheme vaccination. About 200 to 1000 gives providers incentives to immunize yuan are provided for each case children according to established of polio. About 60 to 500 yuan procedures and a recognized schedule of are awarded for each case vaccines. of epidemic cerebrospinal meningitis. A measles case is The EPI prepayment scheme has the compensated with 30 to -500 following characteristics [23-35] (see yuan. details in Annex 2): The two counties in Shaanxi used the EPI · Coverage--in most areas, prepayment scheme with a premium of 12 children ages 0-7 were covered yuan per child, for which the child's by the scheme, while in a few household was entirely (out-of-pocket) areas, it only covered children responsible. According to those ages 0-4; interviewed, the EPI prepayment premium in Shaanxi, which is largely unaffordable · Premiums--there are three types to users, remained unchanged between of premiums collected: whole 1995 and 2002 (Table 3.2). The premiums period (0-7 years or 0-4 years); from the EPI prepayment scheme in per year; and per vaccination. Shaanxi were allocated in the following Premium levels varied from place manner: 6 yuan went to village clinics to place and at different time where the immunization services were periods. In general, premiums provided; 3 yuan went to township health were higher in richer areas than in centers; and 3 yuan to the county disease poorer areas; control center. According to the village clinic heads, these premiums do not cover · Service package--in almost all the operating costs of providing areas, EPI programs were covered immunization services, since the average through a prepayment scheme. In premium is based on predicted birth rates, some counties, Meningococcal which are higher than the actual numbers. and Japanese Encephalitis (JE) In Shandong Province, all counties studied were also covered. Some counties used the fee-for-service method. Between have included Hepatitis B 1995 and 2002, average user fees per immunization in recent years; vaccination increased only nominally, from 1.83 yuan to 5.17 yuan. · Administration--in most cases, the fund was collected by Donor funding -- GAVI and JICA in township health facilities and Shaanxi and JICA in Shandong -- was administered by the county health mainly used for purchasing vaccines. In authorities. The fund was theory, other costs including salaries of 9 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? health providers and supplies should be and Shaanxi, the cost of syringes for covered by the government matching immunization services accounted for only budget. However, in practice, user fees 7%, and 21%, respectively, of total were the source for covering those costs. expenditures. In 2002, in the study counties of Shandong Table 3.2: Collection and Distribution of Revenues from User Charges for Imunization Services Province 1995 2000 2002 Shandong Form of charges Fee-for service Fee-for-service Fee-for service Fee level 1.83 yuan per 4.5 yuan per 5.17 yuan per vaccination vaccination vaccination Fee distribution Syringe - - 0.32 yuan Labor and others - - 4.85 yuan Shaanxi Form of charges EPI Insurance EPI Insurance EPI Insurance Fee level 12 yuan per child 12 yuan per child 12 yuan per child Fee distribution Syringe - - 2.53 yuan Labor and others - - 9.47 yuan 3.1.3 Identified Problems in Financing · The responsibilities of public of Immunization Programs health facilities are unclear under the dual financing system, by Field interviews were conducted as part of which public health services are the study to collect comments and financed by both government suggestions about the financing of subsidies and user fees. Many immunization services including: (i) interviewees identified the dual problems in the current financing policy; financing system as a problem in (ii) possible alternative sources of itself. Public health facilities tend financing for immunization programs; and to use public resources to generate (iii) suggestions for improving the market revenues because the use financing of such services. of and outputs produced by public subsidies are not clearly defined Most interviewees indicated that the role and regulated. Some interviewees of government in financing immunization stressed that even if limitations on services has diminished since the the use of public funds were put introduction of user fees for public health into place, it would still be programs. This causes at least three difficult to control the behavior of problems: health care providers who channel all resources given them so as to · The health care provider has no maximize revenues. financial incentive to provide services with low profit margins, · Health officers in Shaanxi such EPI programs, when other observed that an increase in fees services provide greater revenue. would place children of poor There is too much emphasis by families at risk for not using providers on revenue generation, immunization services. Also given which is understandable given that financial constraints, some poor most health facilities depend on families are only immunizing their revenues from user fees to male children. survive. 10 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Interviewees identified several sources The main recommendations from the that could be explored for increasing interviews were: support to immunization programs, including: · The role of government in financing and organizing · Larger Budget Allocations from immunization programs should be the Government. Additional strengthened. Government government funding was the most budgets, together with frequently mentioned source for international financial aid, could immunization services. Even fully cover the operating costs of though most of the interviewees EPI immunization services recognize the efforts the including labor costs and injection government has made to support materials. The government needs the immunization program, they to pay more attention to think the government could do immunization programs in poor more by redirecting resources for areas to ensure that their financial public health programs. needs are met. The government can also recommend cost effective · Health Insurance Plans. Support procedures for authorized for immunization programs under immunization services. the planned rural health insurance schemes could be considered. · Financial incentives for safe According to the current design of injection practices and appropriate the rural health insurance schemes, disposal of used injection only curative health care is materials should be established. In included in the package. Essential the government budget, a specific public health programs, including line item for encouraging immunization programs, could appropriate disposal of used also be included. injection materials could be set up. This budget item could be used by · Subsidies from the Department of health facilities to purchase Civil Affairs. The current medical disposal equipment and to cover assistance programs focus only on related labor costs. Village clinics medical services provided to that are not reimbursed by regular families under the poverty line. government budgets could, with The assistance programs might financial support from local consider also including support for collectives or upper level health immunization programs targeted facilities, establish standard to children in poor families. procedures for disposal of used injection materials. A bonus can · Donations from Enterprises and be given to reward village clinics Wealthy Individuals. In Shaanxi, that have adopted appropriate donations were mentioned as a disposal methods. way of supporting immunizations not currently included in EPI. · Use of public funding for public Manufacturers of injection health programs should be material could help with the costs regulated. Public funding of disposal of by paying for the allocated to preventive health care transportation of used injection must be used for the provision of materials to be recycled. This is public health services. The being done for upper level health government should establish facilities and could be expanded to regulations including accounting include lower level health units. procedures and management 11 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? information systems to help monitor Table 3.3 presents the proportion of and evaluate the disbursement and disposable syringes used for both use of public funds for health immunization and therapeutic services in programs. Periodical reports on the Shandong and Shaanxi. Except for village use of public funding from health clinics in Shaanxi, all other health facilities should be provided to and facilities used only disposable syringes for assessed by the health authorities. immunization services. Village clinics in Regulators should ensure timely Shaanxi, which are the main providers of correction of any abuse of public immunization injections in the province, finances. used glass syringes for nearly one third of immunization injections. 3.2 The Overall Situation of Injection Safety At study sites in Shandong province, therapeutic injections were mainly This section presents three aspects of safe provided using disposable syringes. Less injection practices in study areas: than 10% of injections were given with utilization of disposable and reusable reusable syringes in village clinics and syringes; disinfection of reusable syringes; township health centers, and no reusable and disposal of syringes. Annex 3 syringes were used in county and city presents the injection safety situation as hospitals. In Shaanxi, on the other hand, documented in the literature. reusable syringes were widely used in township health centers and county 3.2.1 Utilization of Syringes for hospitals. Village clinics used a lower Immunization and Therapeutic Services percentage of reusable syringes than was expected, however. This finding could be due to a bias in the selection of health In Shandong province, 73% of village facilities or to under reporting by staff in clinics, 67% of township health facilities, the clinics investigated. The difference and all county and city health centers used between Shandong and Shaanxi most only disposable syringes. In Shaanxi likely can be explained by economic Province, 33% of village clinics used only differences between the two provinces, disposable syringes. All county and with Shandong health care users being township health facilities in Shaanxi used better able to afford the more expensive a mix of disposable and reusable syringes. disposable syringes. In addition, One city hospital in Shaanxi used only disposable injection material has been disposable syringes while the other used a more widely promoted in Shandong mix of disposable and reusable syringes. Province. 12 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.3: Proportions of Syringes used for Immunization and Therapeutic Services Immunization Therapeutic services Study Site % of % of Reusable % of % of Reusable Disposable Syringes Disposable Syringes Syringes Syringes Shandong City 100 0 100 0 County 100 0 100 0 Township 100 0 95.6 4.4 Village 100 0 90.7 9.3 Shaanxi City 100 0 99.8 0.2 County* - - 66.9 33.1 Township 100 0 48.4 51.6 Village 68.8 31.2 90.8 9.2 *Immunization services are not provided Table 3.4: Methods of Disinfecting Reusable (Glass) Syringes Study site No. of Steamed Boiling Washing Facilities using Reusable Syringes Shandong City 0 - - - County 0 - - - Township 2 2 0 0 Village 17 13 4 0 Shaanxi City 1 1 0 0 County 2 2 0 0 Township 4 4 1 1 Village 8 6 2 0 3.2.2 Sterilization of Reusable Syringes study areas. Table 3.4 presents the methods used for All study sites in Shandong disinfecting by sterilizing reusable syringes and needles. steam used high pressure pots, while in Steam was the most common method of Shaanxi, 3 of 6 village clinics used sterilization for all health facilities that common cooking pots for disinfection. All used reusable syringes. It was noted that of the health facilities reported taking 30 two townships in Shaanxi still used a mix minutes or more to disinfect by steam. of boiling and washing methods. Another Figure 3.1 was taken in a village clinic in observation by the investigators is that the Bin County. It shows the apparatus used procedures and apparatuses used for for sterilizing reusable injection materials. sterilizing injection materials varied across 13 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Figure 3.1: Apparatus used for Sterilizing Reusable Injection Materials in a Village Clinic of Bin County 3.2.3 Disposal of Disposable Injection At township health centers, all the Materials facilities in Shandong burned material after disinfection and destruction, but without properly disposing of the residue Table 3.5 indicates the methods for (burial). In Shaanxi, two of the four disposing of disposable syringes at study township centers disinfected and destroyed sites. Among village clinics in Shandong, injection materials, while only one center a little more than half disinfect and destroy buried the residue. injection materials before disposal, while only 2 out of 12 clinics do so in Shaanxi. Recycling after disinfection and Burning and burial were the main methods destruction was mainly carried out, in both of disposal in both provinces. Three out of provinces, by county and city level the 63 village clinics in Shandong, and 1 hospitals. Manufacturers collected of the 12 village clinics in Shaanxi, disposable injection material from disposed of injection materials without hospitals for recycling, at no cost to these prior disinfection and destruction. hospitals. 14 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.5: Methods of Disposing of Disposable Syringes Study Site No. of Disinfection/ Burning Burial Recycling Reuse Throw Facilities Destruction using Disposable Syringes Shandong City 2 2 0 0 2 0 0 County 3 3 1 0 2 0 0 Township 6 6 6 0 0 0 0 Village 63 33 48 28 5 0 3 Shaanxi City 2 2 0 0 2 0 0 County 2 2 2 0 0 0 0 Township 4 2 4 1 0 0 0 Village 12 2 5 11 0 0 1 Figure 3.2: Containers for containing Medical Wastes in a Village Clinic in Xunyi County 15 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Figure 3.3: The Stove used for Burning Medical Wastes in a County Hospital Safety boxes were not used for storing differences in safe injection practice used injection materials in either province. between the two types of areas, other Medical wastes were stored in common determinants including capacity of health paper boxes. Figure 3.2 demonstrates the workers in implementing safe injection use of such containers in a village clinic in measures, education to the health users, Xunyi county. monitoring and regulating systems could be the focus of the work. Incinerators were not present at any of the health facilities studied. Injection 3.3 Current Utilization and Cost of materials were burned over open fires. Syringes Figure 3.3 shows the stove used in Xunyi Chinese traditional hospital for burning Estimates of costs including cost of medical wastes including used injection syringes (this section and section 3.4) materials. and cost of disposal methods (section 3.5) are direct costs. Costs for supporting the A review of safe injection practice from implementation such as training activities, empirical studies is presented in Annex 3. and costs for monitoring and evaluation of Combined the information from this study the safe injection practice, were not and the literature review, it can be included. This means when a planning is conclude that the overall practice of safe developed, cost information provided from injection is much better in wealthier this study is just part of the total cost for provinces than that in poorer provinces. the safe injection programme. This can be clearly linked to the economic development situations for both health The method for estimating the costs of care users and suppliers. While the purchasing syringes is presented first, practice of safe injection can be further followed by estimates of the number of improved, more attentions for improving injections in 2003, for both immunization safe injection practice in poorer province and therapeutic services. Section 3.3.3 should be paid by the government. Besides applies the costing methodology described financial reasons that may cause the below to the number of injections in 2003 16 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? to arrive at the estimated costs of (2) Cost = Number of target children for purchasing syringes for that year. immunization by age group (<1year; 1-7 years) in 2003 ×Estimated 3.3.1 Method of Costing Syringes for immunization coverage by antigen in Injections 2003 × Number of injections per child as programmed by age group (<1year; Equation (1) was used for estimating the 1-7 years) × Proportion of cost of syringes for therapeutic services. disposable/reusable syringes × Unit price of syringes. (1) Cost = Volume of health services in 2003 x Number of injections per The number of children targeted to receive outpatient visit/per inpatient day × immunizations was determined by the Proportion of disposable/reusable immunization programs. All children syringes × Unit price of syringes. under 7 years of age were covered in this study. The data came from the 2000 The volume of health services was broken National Demographic Census. Children down into the number of visits for under 7 years old were divided into two outpatient services and the number of groups: less than 1 year and 1-7 years, hospital inpatient days. Data on outpatient according to the availability of visits and inpatient days was obtained demographic data. from the National Health Services Survey and Statistical Yearbooks. The number of injections per outpatient visit or per In addition to the immunizations inpatient day was obtained from the prescribed by the EPI program, public facility-based survey. Information on the health specialists recommend proportion of disposable versus reusable Meningococcal and Japanese Encephalitis syringes was obtained from literature vaccines (JE). Given their wide use and review and the facility-based survey. The importance in disease prevention, they unit price of syringes was obtained from were included in cost estimations along the facility-based survey. with EPI vaccines. Table 3.6 presents the seven immunization programs and the Equation (2) was used for estimating the number of injections required to complete cost of syringes for immunization services. each program by the two age groups. Table 3.6: Number of Injections for the Immunization Programs Immunization programs <1 year old 1-7 years old BCG 1 0 DTP 3 1 Measles 1 1 DT 0 1 JE 0 3 Hepatitis B 3 0 Meningococcal 2 1 Total 10 7 17 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.7: Estimated Volume of Service and Injection Ratio in China in 2003 Indicators Country Village Township County City Number of outpatient visits (million) 2902.5 1286.4 704.5 510.6 Number of inpatient days (million) 0 181.0 280.2 257.2 Number of injections per outpatient visit 0.46 0.33 0.19 0.12 Number of injections per inpatient day - 0.21 0.54 0.66 Percent of disposable syringes for therapeutic 65 72 85 100 service Percent of reusable syringes for therapeutic 35 28 15 0 service Number of injections for defined immunization 146.87 (million) Percent of disposable syringes for immunization 78 Percent of reusable syringes for immunization 22 Table 3.8: Estimated Volume of Service and Injection Ratio in Shandong in 2003 Indicators Shandong Village Township County City Number of outpatient visits (million) 212.3 49.9 42.0 91.8 Number of inpatient days (million) 0 21.0 22.2 7.8 Number of injection per outpatient visit 0.61 0.53 0.18 0.12 Number of injection per inpatient day 0 0.30 0.69 0.70 Percent of disposable syringes for therapeutic service 90.7 95.6 100 100 Percent of reusable syringes for therapeutic service 9.3 4.4 0 0 Number of injections for defined immunization 11.52 (million) Percent of disposable syringes for immunization 95 Percent of reusable syringes for immunization 5 Table 3.9: Estimated Volume of Service and Injection Ratio in Shaanxi in 2003 Indicators Shaanxi Village Township County City Number of outpatient visits (million) 79.7 30.4 19.8 25.8 Number of inpatient days (million) 0 4.9 8.1 7.0 Number of injections per outpatient visit 0.31 0.12 0.20 0.11 Number of injections per inpatient day - 0.12 0.38 0.63 Percent of disposable syringes for therapeutic 90.8 48.4 66.9 99.8 service Percent of reusable syringes for therapeutic service 9.2 51.6 33.1 0.2 Number of injections for defined immunization 3.53 (million) Percent of disposable syringes for immunization 60 Percent of reusable syringes for immunization 40 18 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? In this study the term "immunization a total of 5,040 million outpatient visits coverage" reflects the number of and 718 million inpatient days in 2003. immunization injections that are actually About 53.7%, 23.8%, 13.7%, and 8.8% of given -- including unnecessary the total outpatient visits would be at the immunizations (over-provision) -- to village, township, county, and city health children under 7 years old. According to facilities, respectively. Township, county, this definition, immunization coverage and city hospitals would deliver 25.2%, includes: (i) the percentage of children 39.0%, and 35.8% of the total inpatient who are fully immunized, receiving the days, respectively. The expected numbers required number of injections for each of injections, for both therapeutic services antigen; (ii) the percentage of children and immunizations, to be provided by who receive only some of the required different level health facilities are vaccinations; and (iii) the percentage of presented in Table 3.7. children who are given unnecessary immunization vaccinations. Information The total number of injections for for deriving the first proportion is immunization services is not available, but not for the latter two. The disaggregated by type of service because proportions of children who were information on the distribution of "under-vaccinated" and "over-vaccinated" immunization services among the different were determined based on input from levels of health facilities is lacking. provincial and county experts responsible for immunization programs. Tables 3.14 In Shandong, it was estimated that there to 3.16 present estimates for immunization would be a total of 396 million outpatient coverage in 2003, as well as projections visits to health providers in 2003, 53.6% for 2004-2010. Table 3.14 provides of which would be to village clinics, estimated figures for the economically 12.6% to township health centers, 10.6% advanced provinces, including Shandong , to county health facilities, and 23.2% to and Table 3.16 gives estimates for city health facilities. A total of 51 million undeveloped provinces such as Shaanxi. inpatient days was expected to occur in 2003, with 41.3% in township health As shown in Table 3.6, children under the centers, 43.5 % in county hospitals and age of one need to receive 10 injections to 15.2 % in city hospitals. A total of 11.5 be fully immunized, while children ages million immunization injections would, 1-7 years can expect to receive 7 injections therefore, have been provided in Shandong per year. For children aged 1-7 years, an in 2003, with 95% using disposable average of 1 injection is given per child syringes and 5% using reusable syringes per year. The proportion of disposable and (Table 3.8). reusable syringes used for immunization services was obtained from the In Shaanxi, outpatient visits were expected facility-based survey. As mentioned to total 156 million in 2003, with 51.2%, previously, the unit price of syringes was 19.5%, 12.7%, and 16.6% going to village, obtained from the facility-based survey. township, county, and city health facilities, respectively. The total number of inpatient 3.3.2 Number of Injections days would have been 20 million, with 24.4%, 40.5%, and 35.1% being at Data from the National Health Service township, county, and city health facilities, Survey and the demographic census were respectively. About 3.53 million used to estimate the number of expected immunization injections would have been outpatient visits and inpatient days for provided in Shaanxi in 2003, 60% of them 2003. It was estimated that there would be given with disposable syringes (Table 3.9). 19 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? The total estimated numbers of injections The number of injections for in 2003 for all of China are presented in both therapeutic and defined Tables 3.10 and 3.11, by administrative immunization services would level and type of syringe: have totaled 2.5 billion in 2003; About 2.3 billion injections and would have been given for The ratio of therapeutic therapeutic services; injections to defined About 146.8 million injections immunization injections is would have been provided for 15.7:1. defined immunization services; Table 3.10: Estimated Number of Therapeutic Injections in 2003 (million) Therapeutic Injections Disposable Reusable Total Country City 230.3 0 230.3 County 242.4 42.5 284.9 Township 333.0 129.5 462.5 Village 867.8 467.3 1335.1 Total 1673.5 639.3 2312.8 Shandong City 16.5 0 16.5 County 22.9 0 22.9 Township 31.3 1.4 32.7 Village 117.5 12.0 137.5 Total 188.2 13.4 201.6 Shaanxi City 2.8 0.01 2.81 County 3.7 2.3 6.0 Township 2.1 2.2 4.3 Village 22.4 2.3 24.7 Total 31.0 6.81 37.81 Table 3.11: Estimated Number of Immunization Injections in 2003 (million) Immunization Injections Disposable Reusable Total Country 114.56 32.31 146.87 Shandong 10.94 0.58 11.52 Shaanxi 2.12 1.41 3.53 3.3.3 Cost of Injection Syringes China would have needed 625 million yuan in 2003 to purchase syringes Tables 3.12 and 3.13 give estimates for (disposable and reusable) for therapeutic the cost of syringes in China. The prices of injections. Nearly half the cost (44%) of disposable syringes for the country were purchasing syringes for therapeutic estimated using field data from Shandong injections is generated by village clinics. and Shaanxi. The costs of reusable Disposable syringes account for 98% of syringes are based on 120 injections per total purchasing costs. In Shandong, the syringe, as estimated by the health purchase of syringes for village clinics providers interviewed. accounts for more than 50% of total costs, 20 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? with the remainder of costs shared by yuan on the purchase of syringes health facilities at the other three levels. In (disposable and reusable), with Shandong Shaanxi, two thirds of the total cost of province accounting for approximately purchasing syringes for therapeutic 10% of costs. In Shaanxi, half a million services is attributable to village clinics yuan would have been spent for (Table 3.12). purchasing syringes for immunization services. Again, nearly all of the costs can For immunization services, China would be ascribed to the purchase of disposable have been required to spend 35.6 million syringes. Table 3.12: Cost of Syringes for Therapeutic Injections in 2003 (million yuan) No.of Unit Cost No. of Unit Cost Total disposable price (million reusable price (million Cost syringes (yuan) yuan) syringes (yuan) yuan) (million (million) (million) yuan) Country City 230.3 0.69 158.91 0 - - 158.91 County 242.4 0.34 82.42 0.35 2.50 0.89 83.31 Township 333.0 0.31 103.23 1.08 1.53 1.65 104.88 Village 867.8 0.31 269.02 3.89 2.38 9.27 278.29 Total 1673.5 613.57 5.33 11.81 625.38 Shandong City 16.5 0.80 13.20 0 - - 13.20 County 22.9 0.40 9.16 0 - - 9.16 Township 31.3 0.33 10.33 0.01 1.05 0.01 10.34 Village 117.5 0.34 39.95 0.10 2.92 0.29 40.24 Total 188.2 72.64 0.11 0.30 72.94 Shaanxi City 2.8 0.58 1.62 0 - - 1.62 County 3.7 0.27 1.00 0.02 2.50 0.05 1.05 Township 2.1 0.29 0.61 0.02 2.00 0.04 0.65 Village 22.4 0.28 6.27 0.02 1.83 0.04 6.31 Total 31.0 9.50 0.06 0.13 9.63 Table 3.13: Cost of Syringes for Immunization Injections in 2003 (million yuan) No. of Unit Cost No. of Unit Cost Total disposable price (million reusable price (million Cost syringes (yuan) yuan) syringes (yuan) yuan) (million (million) (million) yuan) Country 114.56 0.31 35.51 0.0503 2.13 0.107 35.62 Shandong 10.94 0.32 3.50 0.0048 2.15 0.010 3.51 Shaanxi 2.12 0.23 0.48 0.0009 2.11 0.002 0.48 21 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 3.4 Costs of Ensuring Adequate The proportions of children under one year, Supply of Disposable and AD Syringes and between one and seven years old, were obtained from demographic census This section describes the method used for figures for each province; it is assumed projecting the number of children under that the proportions remain fixed over the one year old, and between 1-7 years old, projected period. for 2004 to 2010, as well as the method for estimating the number of immunization (3) Immunization Coverage injections for each of those years. Then, using current unit prices for disposable As previously mentioned, immunization syringes, costs per immunization program, coverage is the percentage of children out including Hepatitis B, are projected. The of all those targeted who received all, incremental cost of replacing disposable some of, or too many of the required syringes with AD syringes for immunizations. Predictions for future immunization services in 2006 is immunization coverage relied on the presented, followed by the incremental following assumptions: (i) projected trends cost by province of using only AD in immunization coverage are based on syringes for Hepatitis B immunizations. trends in recent years; (ii) current policy governing immunization program 3.4.1 Method of Estimating Costs of financing will remain unchanged for the Ensuring Adequate Supply of Disposable years being projected; and (iii) no and AD syringes large-scale changes will be made to immunization programs during the years Cost projections for supplying disposable in question. and AD syringes were determined using the following assumptions and equations. Immunization coverage, which was All future costs are presented in present projected on the basis of information from value terms. the literature review (see Annex 4) and predictions from experts, was used to (1) Projected Population estimate the number of injections for defined immunization services in the Data from the fifth National Demographic projected years. Three different Census for the year 2000 was used in the predictions of immunization coverage equation below to make population were made corresponding to three projections. different levels of economic development. The criteria for classifying the areas Pn = P0(1+r)n included per capita GDP and baseline immunization coverage. The provinces Where: categorized as economically advanced are: Pn = Number of population in project year; Beijing, Shanghai, Tianjin, Guangdong, P0 = Number of population in 2000; Jiangsu, Zhejiang, and Shandong. The r = Growth rate of population; and middle provinces are: Fujian, Hubei, n = years from 2000 to the project year Sichuan, Liaoning, Jilin, Heilongjiang, Shanxi, Jiangxi, Hunan, Hainan, Hebei, (2) Projected Number of Children Less Xizang, Anhui, and Chongqing. The than One (1) Year Old and 1-7 Years Old underdeveloped provinces are: Guizhou, Shaanxi, Gansu, Yunnan, Neimeng, Henan, Projected number of target children = Pn × Guangxi, Qinghai, Ningxia, and Xinjiang. Proportions of children in total population. 22 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Tables 3.14 to 3.16 show projected (2004-2010). Prices of syringes in each of immunization coverage for the three types project years were adjusted using GDP of areas. growth rate taking the value in 2003 as the base. (4) Unit Prices of Syringes (5) Estimation of Cost It was assumed that the prices of syringes in project years in real terms would be the The equation below was used to arrive at same as present prices. This means we projected costs of syringes for took current prices of syringes to estimate immunization services. the costs in projected years. Cost = Number of target children in a GDP growth rate was used for correcting given year × Number of injections for the inflation for project years. It was each child as programmed × Immunization assumed that the GDP growth rate in coverage as predicted × unit price of recent years (8% annually) will be syringes. constant in the projected time period Table 3.14: Projected Immunization Coverage for Advanced Provinces Programs 2003 2004 2005 2006 2007 2008 2009 2010 BCG 80 80 80 85 85 90 90 95 DTP 75 80 80 85 85 90 90 95 Measles 80 80 85 85 85 95 95 95 DT 75 75 80 80 85 85 90 95 JE 60 65 65 65 70 70 75 80 Hepatitis B 40 55 60 65 70 70 75 85 Meningococcal 60 65 65 65 70 70 75 80 Table 3.15: Projected Immunization Coverage for Mid-Income Provinces Programs 2003 2004 2005 2006 2007 2008 2009 2010 BCG 75 75 75 80 85 85 85 90 DTP 70 75 80 80 80 85 85 90 Measles 75 75 80 80 85 90 90 90 DT 70 70 75 75 80 85 85 90 JE 50 55 55 55 60 60 65 70 Hepatitis B 25 25 30 45 45 65 70 80 Meningococcal 50 55 55 55 60 60 65 70 Table 3.16: Projected Immunization Coverage for Underdeveloped Provinces Programs 2003 2004 2005 2006 2007 2008 2009 2010 BCG 70 70 75 75 80 80 85 85 DTP 65 65 70 75 75 80 80 85 Measles 75 75 75 80 85 85 85 85 DT 65 65 70 75 75 80 80 85 JE 45 45 45 50 50 50 60 60 Hepatitis B 10 15 15 40 40 55 60 70 Meningococcal 45 45 45 50 50 50 60 60 23 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 3.4.2 Number of Injections for Table 3.17 presents the number of Immunization Programs injections in China for each of the seven years by immunization programs. In 2005, The number of target children in a given about 155 million immunization injections year, the number of injections for each will be given, and that number will child as programmed (Table 3.6), and increase to 211 million by 2010. The predicted immunization coverage (Tables largest increases in coverage are expected 3.14 to 3.16), together generate the to occur in Hepatitis B, DT, numbers of injections for 2004 to 2010. Meningococcal, and JE. Table 3.17: Projected Numbers of Injections for Defined Immunization Programs (million) Programs 2004 2005 2006 2007 2008 2009 2010 BCG 10.59 10.91 11.47 12.12 12.37 12.71 13.30 DTP 42.55 45.11 47.08 47.43 50.80 51.16 54.60 Measles 22.76 23.97 24.61 26.00 27.58 27.78 27.98 DT 10.93 11.80 12.11 12.77 13.50 13.80 14.68 JE 25.68 25.86 26.73 28.62 28.82 32.17 34.13 Hepatitis B 12.19 13.71 20.74 21.39 27.60 30.02 34.70 Meningococcal 23.91 24.08 24.96 26.68 26.90 30.09 31.88 Total 148.61 155.44 167.70 175.01 187.57 197.73 211.27 3.4.3 Projected Costs of Syringes purchasing disposable syringes in 2004 to 2010, as shown in Table 3.18. The The projected numbers of injections assumption for this table is that only combined with the unit price of disposable disposable syringes will be used as of syringes provide the projected costs of 2004. Table 3.18: Projected Cost of Injections using Disposable Syringes for Defined Immunization Programs (million yuan) Programs 2004 2005 2006 2007 2008 2009 2010 BCG 3.49 3.93 4.47 5.09 5.57 6.23 7.05 DTP 14.04 16.24 18.36 19.92 22.86 25.07 28.94 Measles 7.51 8.63 9.60 10.92 12.41 13.61 14.83 DT 3.61 4.25 4.72 5.36 6.08 6.76 7.78 JE 8.47 9.31 10.42 12.02 12.97 15.76 18.09 Hepatitis B 4.02 4.94 8.09 8.99 12.42 14.71 18.39 Meningococcal 7.89 8.67 9.73 11.21 12.11 14.74 16.90 Total 49.04 55.96 65.40 73.50 84.41 96.89 111.97 Table 3.19 shows the costs of giving and number of injection per child remain immunization injections using AD the same as in subsection 3.4.2. In 2006, syringes exclusively, beginning in 2006. 147.6 million yuan will be required for the According to the findings of this study, the purchase of AD syringes for use in defined unit price of an AD syringe is 0.70 yuan. immunization programs. By 2010, 251.4 Other assumptions, including number of million yuan, at present monetary value, target children, immunization coverage, will be needed. 24 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.19: Projected Cost of Injections using AD Syringes for Defined Immunization Programs (million yuan) Programs 2006 2007 2008 2009 2010 BCG 10.09 11.51 12.74 14.11 15.83 DTP 41.43 45.06 52.32 56.79 64.97 Measles 21.66 24.70 28.41 30.84 33.30 DT 10.66 12.13 13.91 15.32 17.47 JE 23.52 27.19 29.68 35.71 40.61 Hepatitis B 18.25 20.32 28.43 33.32 41.29 Meningococcal 21.96 25.35 27.71 33.40 37.94 Total 147.58 166.26 193.20 219.48 251.41 Table 3.20: Projected Incremental Cost of Injections using AD Syringes replacing Disposable Syringes for Defined Immunization Programs (million yuan) Programs 2006 2007 2008 2009 2010 BCG 5.62 6.42 7.17 7.88 8.78 DTP 23.07 25.14 29.46 31.72 36.04 Measles 12.06 13.78 15.99 17.22 18.47 DT 5.93 6.77 7.83 8.56 9.69 JE 13.10 15.17 16.72 19.95 22.53 Hepatitis B 10.16 11.34 16.01 18.61 22.90 Meningococcal 12.23 14.14 15.60 18.66 21.04 Total 82.17 92.76 108.79 122.59 139.44 Based on the cost estimates for disposable amount needed for Hepatitis B. and AD syringes presented in Tables 3.18 and 3.19, the incremental cost of Table 3.21 presents the incremental cost immunization programs switching to AD (from 2006 to 2010) of replacing syringes was calculated. Table 3.20 shows disposable syringes with AD syringes for that in 2006, it will cost China 82.2 defined immunization programs by million yuan to replace disposable province. In most of the western provinces, syringes with AD syringes for injections an increase of less than 3 million yuan will given under the seven immunization be enough for replacing disposable programs, with 10.2 million yuan of that syringes with AD syringes in 2006. 25 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.21: Projected Incremental Cost of AD Syringes replacing Disposable Syringes for Defined Immunization Program by Province (million yuan) Province 2006 2007 2008 2009 2010 TOTAL 82.17 92.76 108.79 122.59 139.44 Beijing 0.63 0.71 0.81 0.89 1.01 Tianjin 0.52 0.59 0.67 0.74 0.84 Shanghai 0.71 0.80 0.90 1.00 1.13 Jiangsu 4.14 4.68 5.31 5.91 6.71 Zhejiang 3.12 3.52 4.00 4.45 5.06 Shandong 6.31 7.13 8.11 9.03 10.28 Guangdong 6.76 7.68 8.78 9.83 11.23 Hebei 4.33 4.93 5.87 6.55 7.50 Shanxi 2.47 2.82 3.37 3.77 4.34 Liaoning 2.15 2.44 2.89 3.22 3.67 Jilin 1.38 1.57 1.87 2.08 2.38 Heilongjiang 1.85 2.10 2.49 2.78 3.17 Anhui 3.93 4.49 5.36 5.99 6.88 Fujian 2.00 2.27 2.70 3.01 3.44 Jiangxi 3.31 3.78 4.53 5.07 5.83 Hubei 2.96 3.38 4.00 4.45 5.09 Hunan 3.87 4.40 5.23 5.82 6.66 Hainan 0.62 0.70 0.85 0.95 1.10 Chongqing 1.87 2.13 2.52 2.80 3.20 Sichuan 5.25 5.99 7.11 7.93 9.08 Xizang 0.28 0.32 0.39 0.44 0.51 Neimenggu 1.30 1.44 1.69 1.95 2.18 Henan 6.13 6.77 7.98 9.21 10.34 Guangxi 3.09 3.42 4.03 4.65 5.22 Guizhou 3.40 3.78 4.49 5.21 5.89 Yunnan 3.73 4.14 4.91 5.68 6.41 Shaanxi 1.96 2.16 2.52 2.91 3.26 Gansu 1.77 1.96 2.31 2.67 3.00 Qinghai 0.40 0.45 0.54 0.61 0.69 Ningxia 0.47 0.52 0.62 0.72 0.81 Xinjiang 1.47 1.63 1.93 2.23 2.52 The government is planning to cover at control and prevention in each province. least 70% of the cost of purchasing AD Government health budget and budget for syringes for the western provinces. Table disease control were adjusted using the 3.22 shows the amount the twelve GDP growth rate (8% annually) taking the provincial governments would have to value in 2000 as the base. spend on AD syringes for immunization (costs for purchasing AD syringes in 2006 If the government were to cover 70% of were used). The costs to be covered by the cost of AD syringes in each of the 12 government budgets are also presented as western provinces, it would take 0.09 to a percentage of the total government 0.49% of provincial health budgets, and health budget in each province, and as a 0.72 to 3.38% of the budgets for disease percentage of the budget for disease control and prevention. 26 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.22: Estimates of Government Budgets allocated to Purchasing of AD Syringes and Costs as a Proportion of Health Budgets in Western Provinces in 2006 Cost of AD Government Syringes Health Budget covered by Total for Disease Government Government Control and Budget (10,000 Health Budget Prevention Provinces yuan) (10,000 yuan) Percent (10,000 yuan) Percent (1) (2) (1)/(2) (3) (1)/(3) Chongqing 234.7 68305.7 0.34 8203.8 2.86 Gansu 222.4 71334.1 0.31 11588.8 1.92 Guangxi 388.7 91406.2 0.43 13058.6 2.98 Guizhou 427.5 86860.9 0.49 12632.3 3.38 Neimenggu 163.7 83907.9 0.20 18819.2 0.87 Ningxia 59.1 24735.7 0.24 3816.3 1.55 Qinghai 50.5 23069.2 0.22 4642.2 1.09 Shaanxi 245.8 80702.1 0.30 12568.2 1.96 Sichuan 659.7 182606.5 0.36 24900.9 2.65 Xinjiang 184.8 100709.2 0.18 13159.5 1.40 Xizang 35.1 40743.0 0.09 4895.5 0.72 Yunan 468.8 164892.7 0.28 27950.3 1.68 3.5 Cost of Disposal Methods Use of safety box(es) The method for estimating the cost of Disinfection/destruction disposing of used injection materials Recycling appears below, followed by the estimated Burning including costs of various disposal methods, incineration including disinfection/destruction, burning, Burial. burial, and safety box. (2) Estimating Costs 3.5.1 Method for Estimating the Cost of In order to estimate costs, each method Disposing of Used Injection Materials had to broken down into the following inputs: capital, labor, transportation, and A two-step procedure was used for supplies. Below are equations for costing estimating costs to dispose of injection each input. materials. First, the primary cost components of disposal were identified; (i) Capital and then the method for estimating the Safety box: pieces used per cost of each component was developed. year × unit price; Incinerator: price per piece (1) Methods of Collection, Disinfection, × pieces per year/duration of and Destruction of Syringes and Needles years usable (annualized cost); and This is based on a review of documents on Open burning: cost per disposal practices in developing countries, piece a year. interviews with immunization officers, and observations in the field. A health facility's (ii) Labor system of disposal may, in fact, include Working days used for one or more of the following methods or disposal of injection practices: materials a year × daily income; 27 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? (iii) Transportation provinces. Township health centers in Cost per trip × number of Shandong spend about 1,000 yuan a year trips per year (Travel to to burn disposable material, which is 882 places for collection or yuan more than in township health centers recycling); and in Shaanxi. Labor in county hospitals (iv) Supplies comprises 44% of total burning costs in Supplies include fuel or Shaanxi, and 63% in Shandong (Table other types of material for 3.24). burning and sterilization. In Shandong, burial is used only in village The total cost of each disposal system (a clinics, whereas in Shaanxi it is performed method or combination of methods) was in township health centers as well. Labor calculated as the sum of the input costs. costs for burial ranged from 18.5 to 36.6 yuan in the facilities that used this method 3.5.2 Costs of Disposal Methods of disposal. As previously mentioned, health facilities that participate in Cost of disinfection and destruction of recycling, pay nothing for those services. disposable syringes is reported in Table 3.23. In the study sites of Shandong The investigators were shown samples of Province, disinfection and destruction at safety boxes that are to be introduced for the village level requires 135 yuan a year, Hepatitis B immunization services in 23% of which is spent on labor and 77% Shandong and Jinan Centers for Disease on supplies. Costs for disinfecting and Control. No other types of safety boxes destroying used injection material at were found at the study sites. The cost of a township health centers and county safety box was estimated based on the hospitals are considerably higher in sample safety box. It is assumed that a Shandong than in Shaanxi. This is likely safety box contains 500 disposable needles, attributable to the difference in volume of and the time for cutting a needle is 30 health services between the two areas. The seconds. Based on these assumptions and difference in costs between the two the estimated number of injections at study provinces is much smaller for city sites, the cost of using a safety box was hospitals. Labor costs in city hospitals calculated (the current unit price per safety account for about 31% of the total cost of box is 20 yuan in Shandong, and is disinfection and destruction in each assumed to be the same for Shaanxi where province. no safety boxes were found). The results are presented in Table 3.25. The total cost Costs for burning disposable injection for using safety boxes is much greater in material were low because incinerators Shandong than in Shaanxi, mainly due to were not used. Burning injection material the higher number of injections in the costs less than 100 yuan a year in both former, as well as higher labor costs. Table 3.23: Cost of Disinfection and Destruction of Disposable Syringes in 2002 (yuan) Sites Total Cost Labor Supply Depreciation Shandong Village 134.9 31.3 103.6 0 Township 1988.8 346.7 1642.1 0 County 13274.6 3897.8 7908.1 1469.7 City 141469.0 44229.0 91615.0 5625.0 Shaanxi Village - - - - Township 254.0 34.0 220.0 0 County 2156.1 836.1 1320.0 0 City 120077.5 37277.5 82300.0 500.0 28 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.24: Cost of Burning Disposable Syringes in 2002 (yuan) Sites Total cost Labor Supply Depreciation Shandong Village 81.9 56.3 20.6 5.0 Township 1003.4 281.4 683.9 38.0 County 2299.9 1459.9 720.0 120.0 City - - - - Shaanxi Village 43.9 31.0 12.9 - Township 343.9 227.2 110.8 6.0 County 1964.5 836.1 1095.0 33.3 City - - - - Table 3.25: Cost of Safety Boxes for Disposable Syringes per Year (yuan) Sites Total Cost Cost of Labor No. of No. of Safety Box Safety Injections Boxes/Year Shandong Village 141.9 107.9 34.0 5.4 2696.1 Township 3150.1 1783.3 1366.8 89.2 44583.3 County 16754.0 7365.9 9388.1 368.3 184148.7 City 79031.4 19528.0 59503.4 976.4 488200.0 Shaanxi Village 32.4 28.0 4.4 1.4 698.9 Township 83.4 52.4 31.0 2.6 1309.0 County 1701.2 867.5 833.7 43.4 21688.0 City 47578.1 18724.9 28853.2 936.2 468122.5 Table 3.26: Cost of Combined Methods for Disposal of Syringes (yuan) SB+BN+BR SB+BN DD+BN+BR DD+RC DD+BR BN+BR Shandong Village 260.4 223.8 171.5 134.9 171.5 118.5 Township - 4153.5 - 1988.8 - - County - 19053.9 - 5447.3 - - City - 79031.4 141469.0 - - Shaanxi Village 94.8 76.3 - - - 62.4 Township 462.1 427.3 597.9 254.0 288.8 378.7 County 3665.7 3665.7 - 2156.1 - - City - 47578.1 - 120077.5 - - Safety Box (SB); Burning (BN); Burial (BR); Recycling (RC); Disinfection/Destruction (DD) Table 3.26 shows total costs for feasible and county health facilities in both alternative systems, derived by combining provinces, a system of disinfection/ the costs for the methods previously destruction and recycling is least costly. described. The combination of burning For city hospitals in Shandong and and burial is the most cost-effective Shaanxi, the use of safety boxes, together method of disposal for village clinics in with burning, is cheaper than both Shandong and Shaanxi. At township disinfection/destruction and recycling. 29 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 3.6 Viability of Disposal Methods community safety; health care provider safety; environmental regulations; and WHO has recommended a series of acceptability to health care providers. strategies for the development of safe Interviewees were then told to rate the injection policy and practice [36]. These viability of each disposal practice. strategies include education and training Interviewees gave one point to the practice of health providers on safe injection and or component they thought was most disposal of used material, and the viable. Five points were given to the establishment of monitoring and practice they deemed least viable. supervision systems to ensure that proper procedures are followed. WHO strongly Table 3.27 presents the average points for recommends placing used injection each practice rated by the interviewees. material in safety boxes or puncture-proof Even though each of the five factors containers [37]. A collection system for influencing viability was explained to the disposing of full safety boxes or sharps interviewees, it seems that most of the containers should be available. The best interviewees gave extra weight to practice is to have these containers perceived costs and practicality. At village transported to county level health facilities clinics in Shandong and Shaanxi, burning where incinerators for burning them are and burial were the preferred choices, available. In remote areas where safety mainly because interviewees thought those boxes or puncture-proof containers are not methods were easier to manage. They did available, used injection materials should not realize that burning and burial must be be burned and buried in deep pits. preceded by disinfection and destruction. Interviewees from health facilities in The disposal of used injection material at Shandong tended not to favor safety boxes study sites was rarely carried out because they thought they might be too according to WHO-recommended best costly. At the county and city level, practices. For instance, none of the health Shaanxi interviewees opted for recycling facilities participating in the study used because it is offered to them free of charge. safety boxes or puncture-proof containers. This seems to imply that if recycling Investigators conducted interviews with services were expanded through public health officials and personnel concerning funding, health facilities would widely the viability of various methods. embrace recycling as a method of Interviewees were asked to consider five disposal. factors that influence viability: costs; Table 3.27: Average Points given to Each Disposal Practice/Component Burial Safety Box Burning Disinfection/ Recycling Destruction Shandong Village 3.18 3.97 1.98 2.81 3.06 Township 3.83 4.83 2.00 1.33 3.00 County 4.67 4.33 2.33 1.00 2.67 City 5.00 2.50 3.00 1.50 3.00 Shaanxi Village 2.18 3.82 2.27 2.91 3.82 Township 4.25 1.50 3.00 3.25 3.00 County 4.50 3.00 3.00 3.50 1.00 City 5.00 2.50 2.50 3.50 1.50 30 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Scores were also calculated for the Combining the cost information presented alternative systems of disposal (first in Table 3.25 and the rankings shown in presented in Table 3.26), which represent Table 3.28, the least costly and most feasible and effective combinations of acceptable disposal systems under present methods. Every combined method was conditions would be: (i) burning and given a score by averaging together the burial for village clinics; and (ii) 1-5 ratings of each component involved, disinfection/destruction and recycling for with 1 being the most viable and 5 the township, county, and city health facilities. least. Table 3.28 presents the feasibility ranking for each of the combined methods Table 3.29 presents the estimated costs of by level of health facility. disposing of used injection material in each of the five counties studied. Costs The combination of burning and burial were calculated by using the combined scored best among village clinics in both disposal method with the best ranking at provinces. In township, county, and city each health level. There are two steps for hospitals in Shandong, the winning calculating the costs for each county. combination was disinfection/destruction First, a unit cost for the disposal method and recycling. Among Shaanxi township preferred at each level of health facility facilities, the combination of safety boxes (e.g., burning and burial at village clinics) and burning outperformed other combined was established and then multiplied by the methods. However, this method's winning total number of health facilities at that rank was in part due to the level. Secondly, the totals for each level assumption--based on the availability of were added together to give the total cost free recycling to Shaanxi health facilities for each county to dispose of all used higher than village clinics-- that the safety injection material. The table also shows boxes would be collected and taken to an the reduction in costs to each county if the incinerator free of charge. At the county government were to underwrite a level in Shaanxi, the combination of significant proportion of disposal costs. disinfection/destruction and recycling had With the government covering 70% of the best ranking. For city health facilities costs, each county in Shandong could in Shaanxi, two methods tied for most safely dispose of all of its injection feasible: safety boxes and burning; and material for less than 100,000 yuan a year. disinfection/destruction and recycling. Under the same scenario, Shaanxi's two counties would need less than 21,000 yuan each. 31 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table 3.28: Feasibility of Combined Methods for Disposal of used Injection Materials SB+BN+BR SB+BN DD+BN+BR DD+RC DD+BR BN+BR Shandong Village (Score) 3.04 2.98 2.66 2.94 3.00 2.58 Order 6 4 2 3 5 1 Township 3.55 3.42 2.39 2.17 2.58 2.92 (Score) Order 6 5 2 1 3 4 County (Score) 3.78 3.33 2.67 1.84 2.84 3.50 Order 5 4 2 1 3 5 City (Score) 3.50 2.75 3.17 2.25 3.25 4.00 Order 5 2 3 1 4 6 Shaanxi Village (Score) 2.76 3.05 2.45 3.37 2.55 2.23 Order 4 5 2 6 3 1 Township 2.92 2.25 3.50 3.13 3.75 3.63 (Score) Order 2 1 4 3 6 5 County (Score) 3.50 3.00 3.67 2.25 4.00 3.75 Order 3 2 4 1 6 5 City (Score) 3.33 2.50 3.67 2.50 4.25 3.50 Order 3 1 5 1 6 4 Safety Box (SB); Burning (BN); Burial (BR); Recycling (RC); Disinfection/Destruction (D/D) Table 3.29: Costs of Preferred Methods of Disposal of used Injection Materials in the Study Counties in 2002 Total Cost 50% of Cost covered 70% of Cost covered by (yuan) by Government Government Budget(yuan) Budget (yuan) Shandong Sishui 82868 41434 58008 Weishan 123075 61538 86153 Zhoucheng 138001 69000 96600 Shaanxi Yunyi 25458 12729 17821 Bin 29744 14872 20821 32 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 4. Discussion demonstrated in other developing countries. Large proportion of HIV/AIDS The China's health care financing reform cases utilize injections for drug abuse in has led to the increasing importance of China, which shows the importance of user fee in covering costs of public health improving practice of safe injections for programs including immunization this special population group. Shi reported programs. Costs of labor and injection that about 18 billion Chinese yuan was materials for EPI were covered by users spent on treating hepatitis B patients and and costs of disposal of used injectiables the ratio of benefit over cost of AD were covered by the health care providers. syringes replacing disposable syringes In the poorer province, a proportion of ranged 32.5 to 07.4 in 2001 [1]. health facilities still used re-usable syringes for both immunization and This study focuses on the issues of therapeutic services. Modern steam financial elements in relation to support of sterilizers were not widely used by lower immunization programs. However, this level health providers, especially in the does not mean financing issue is the only poorer province. Incinerators and safety determinant affecting implementation of box recommended by WHO and MOH for immunization programs. Source of finance disposal of used injection materials were is one of the preconditions for delivering not widely used in both wealthier and public health programs, but not poorer provinces. To ensure supplies of automatically lead to better practice of disposable and AD syringes for public health services. How health immunization programs in the future years resources can be reasonably allocated to will cost a small portion of health strengthen capacity of health workers in expenditures. delivering health care, and to increase affordability of health care users in use of International studies have provided lots of public health programs, is more important. evidences on prevalence of unsafe While the situation of shortage of injection practice and its consequences. resources for financing essential public Besides the problem in provision of health programs should be seriously aware, unnecessary injections with an estimate of appropriate use of resources including 70% in total injections, more than 50% of training for both health care workers and the injections were unsafe in developing users should be considered. countries [38]. Unsafe injections result in tremendous burdens of both diseases and WHO has identified three main reasons for costs. About 33% of HBV infections and unsafe injections: lack of awareness of the 42% of HCV infections in developing and risks of reuse of syringes; shortages of transitional countries are caused by unsafe syringes and needles; and the absence of injections [39]. In South Asia up to 9% of facilities for the safe collection of used new HIV cases may because by unsafe use injection equipment [42]. Making of a of injections [39]. It was estimated that national plan of actions towards safe 80,000 to 160,000 HIV/AIDS cases may injection practice and monitoring and be caused by reuse of syringes and needles evaluation of the plan implementation are without sterilization annually in the world strongly recommended [43]. The financial [40]. Unsafe injections also lead to a direct reasons for constrain expansion of cost of 535 million US$ a year [41]. immunization programs and supplies of safer injection materials were presented in China is a high endemic country with the result section. We below discuss the HBV and HCV and is facing increasing lack of awareness of the risks of unsafe threats of HIV/AIDS. Even though there is injections and absence of facilities for no evidence to clearly clarifying the disposal of injection equipment. contributing factors to high prevalence of HBV and HCV, unsafe injections would Lack of awareness of the risks resulted play a crucial role for the prevalence as from unsafe injections could be for both 33 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? injection users and providers. From user Even if the China's government has side, education about health consequences developed action plan for improving of safe injections may not be delivered practice of safe injection, no evidence is sufficiently to the general public which found about the monitoring and evaluation affects the needs of users for safer of implementation of the plan. Regular injection materials. In rural areas, health and reasonable evaluation of the plan education programs were not carried out implementation is necessary for effectively. Mixed use of reusable and identifying priorities of problems for disposable syringes in some village clinics intervention in safe injection practice. in this study provided choice for users. However, it might be that only information 5. Policy Recommendations on price of disposable syringes was informed to the users. There might lack Correct Financial Incentives for Public explanations about the advantages of Health Care Providers. Current financial disposable syringes for ensuring safety to incentives lead public health facilities to the users. From injection provide side, neglect less profitable preventive health training of the safe injection practice may care services, in general, and injection not be enough or absent. Training safety in particular. In order to address this programs for health providers usually problem, the government should consider: focused on therapeutic knowledge and skills. Training on safe injection practice · Separate accounting systems for may be ignored. This would especially free immunization services and happen for rural health facilities. The for-profit preventive care to assure injection providers without education may appropriate use of public monies. underestimate the potential risks for both The Government needs to clearly themselves and the communities. define the responsibility of public health care providers and regulate Both wealthier and poorer provinces in the allocation of public funds. this study showed limited use of standard Most importantly, EPI funds incinerators and safety box for disposal of should not be used for the used injection equipment. This could provision of for-profit health care; imply that financial reason can not be the only explanation for choice of disposal · Establishing a specific fund for methods. One possible factor influencing the purchase, distribution, and safe use of disposal system is lack of disposal of injection material for coordination for collective disposal of immunization services. If used injection materials. Health facilities, carefully regulated, such a fund especially small-scale ones, usually have would motivate health care limited quantities of medical wastes within providers to properly use and certain time period. Expensive equipment dispose of injection materials; and for disposal of the medical wastes can not be efficiently utilized. This would not · Increasing subsidies to poorer encourage health facilities to purchase the areas to ensure equal access to equipment. If incinerators can be installed new, safer injection technologies in a certain point and shared by a number and encourage the adoption and of health facilities in rural areas, use of continued practice of safe appropriate equipment could be increased. injection and disposal practices. Limited use of safety box could be mainly contributed to the complexity of its Reassess User Fees. The impact of user utilization, bedsides price matter. Another fees on the behavior of health care reason may be that health providers do not providers and users of immunization realize the advantages to use of safety box. services is not yet well understood. On the This needs introductory training to health one hand, increased revenue from user care providers to use this type of products. fees could motivate health care providers 34 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? to expand and improve immunization Develop and Institute Protocols for services. On the other hand, higher fees Disposal of Used Injection Materials. may dissuade people, particularly the poor, Methods for disposing of used injection from seeking immunization services. The materials vary by setting. Cost-effective policy guiding user fees in the public methods acceptable to immunization health sector should be revisited to providers in different localities or at examine its possible negative impact on different administrative levels should be utilization of immunization programs. developed. Based on cost and preferences expressed by those interviewed, the Ensure the Supply of Safe Injection research team suggests: Materials. The government needs to play a leading role in the organization and · At village clinics, burning and provision of safe injection materials. burial should be the norm. Compared to total health expenditures and Recycling, too, should be the resources allocated to tertiary hospital considered provided it is free of services, the cost of upgrading current charge to village clinics, as is injection materials is minimal. The the case for higher-level government could make safer injection facilities; and practices financially feasible by: · At township, county, and city · Redirecting financial resources health facilities, disinfection/ away from medical services destruction and recycling should and toward public health care; become standard procedure. · Increasing public funds for Strengthen Training Programs for Safe safe injection programs. The Injection Practice. Behavior of injection China's government has made providers is one of the crucial substantial increase of budget determinants for injection safety. Training in public health programs. programs should be well organized and Budget for programs for sufficiently offered to health providers to improving safe injection increase their awareness of risks of the practice should be reasonably unsafe injection and their skills of using considered; and appropriate system for sterilization and · Requiring central and local destruction of used injection material. governments to share the cost Education to the general public is also of replacing older technologies required to increase awareness of the risks with new ones. of unsafe injections for the communities. 35 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? References 11. Cai, R. A Review of Reforming China's Employee Basic Health Insurance 1. Shi G, Xie YF, Zhang Y, Liu XY. System. In Proceedings of Reforming Cost-Benefit Analysis of AD Syringes. Health Services for Equity and Efficiency Chinese Journal of Epidemiology, 2003, in Urban China held in Beijing on 4-6 24(3): 180-183. December 2001. 2. Yu J. Review of Unsafe Injection in 12. Gao, J. and Tang S. Health Insurance China. Unpublished document, Shandong and Hospitalization in Urban China: University, 2003. Bending to the Wind of Change. World Hospitals and Health Services, 2000, Vol. 3. Department of Disease Control of 36. No.3: pp23-26. Ministry of Health. Baseline Survey for Health VIII Project. China Immunization 13. Ministry of Health. Health Finance Journal, 1998, 411-9. Report. Unpublished report, Beijing, 2001, p129. 4. Li YX. Investigation on Current Status of Safe Injection of Preventive Inoculation 14. China Institute of Health Economics. in Five Provinces of Western China and Health Expenditure Report 1992-2000. the Affecting Factors. Chinese Journal of Beijing, 2000. Vaccines and Immunization; 2002, 8 (6): 241-243. 15. Institute of Health Economics, Ministry of Health. Report on Health 5. Zhang YH. An Investigation on the Expenditures 1990-1995. Unpublished Safety Injection Status of EPI data. Immunization of Grass-roots of Puyang City in Henan Province. Chinese Journal 16. Zhao YX, Wan Q, Gao G, Du L. Health of Epidemiology; 2003, 24 (3): 175. Expenditures in China 2001. Chinese Journal of Health Economics, 2003, 6. Unsafe Use of Injections and The 3(22):1-3. Transmission of HIV. Network for Infectious Diseases, 2002, (4): 3. 17. Tang S and Bloom G. Decentralizing Rural Health Services: A Case Study in 7. Yuan JH Loni G. Projection of China. International Health Planning HIV/AIDS: Situation in Yunan Province. Managementt, 2000,15:189-200. Chinese Journal of STI &HIV, 2002 82 78-81. 18. Meng Q, Li R, Cheng G, and Blas E. Provision and Financial Burden of TB 8. Luo YSun X. Children's Eye Injuries. Services in a Financial Decentralized Journal of Eye Injuries, 2000223 System: A Case Study from Shandong, 268-269. China. 2003 (Submitted manuscript). 9. Li Q, Ou JM, etc. Investigation on Safe 19. Xinhua News Agency. Chinese Injection Status of Medical Organizations Communist Part Committee and the State in Wulong County in Chongqing City. Council: Decision About Developing Chinese Journal of Epidemiology; 2003, Rural Health Care and Financing Systems. 24 (3): 176-179. 2002. 10. United Nations Task Force on Health. 20. Ministry of Labor and Social Security Report on Health in China. Unpublished and State Bureau of Statistics. Labor and report, Beijing, 2000. Social Security Report, 2002. 36 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 21. China State Council. Decision About 31. Meng XJ, Fang ZZ, Zang SB. The Urban Health Insurance Reform. Applying Immunization Insurance System Economics Press, 2000. and Promoting The Quality of Our Job Thoroughly[J]. Modern Preventive 22. Ministry of Health. Planning for Medicine, 1998253358-359. Strengthening Public Health Programs. Unpublished document, 2003. 32. Zhang XQ, Pu ZL, Zou YX, etc. State Analysis of Immunization Insurance 23. Zhang MC, Zhu B. The Content and System in Rushan County [J]. Literature Assessment of Immunization Insurance and Information of Preventive Medicine, System [J].Chinese Health Economics, 199954:394. 1989652-54. 33. Zhao XJ, Du JL. The Administration 24. Yuan LT, Yu JC, Qin CK. The and Usage of Immunization Insurance Management and Benefit Evaluation of Fund [J]. Chinese Journal of Public Health Immunization Insurance Fund in Dafeng Mangement:Supplement, 1992,8(A08) County[J]. Jiangsu Preventive Medicine, 32,28. 1994238-39. 34. Xu YF, Cao YS, Tian W, etc. Primary 25. Gao Y. The Problem and Solution of Exploration of Using Children Compensation After Pursuing Immunization Insurance Fund Immunization Insurance System [J]. Reasonably[J]. Chinese Journal of Public Jiangsu Preventive Medicine, 19941 Health Management, 199174231-232. 22-23. 35. Yao Y, Xie ZL, Zheng F, etc. The 26. Bao LB. The Analysis of Relationship Effect Appraisal of Practicing Between Immunization Insurance System Immunization Insurance System in and Immunization Coverage Rate of Four Taining County[J]. Strait Journal of Kind of Vaccines in Chengdong Town of Preventive Medicine, 19951148-49. Qingyang County[J]. Anhui Preventive Medicine, 19962476. 36. Battersby A., Feilden R., Stoeckel P., et. al. Strategies for Safe Injections. 27. Wang X,Tian YB. Some Experience of Bulletin of the World Health Organization, Pursuing Immunization Insurance 1999, 77(12):996-998. System[J]. Neimenggu Preventive Medicine, 1997223133-134. 37. Yvan Hutin, Anja Hauri, Linda Chiarello, Mary Catlin, Barbara Stilwell, 28. Tesfamicael Ghebrehiwet, Julia Garner, http://www.gdaw.gov.cn/new/fzgh/f5.htm and the Members of the Injection Safety Best Practices Development Group. Best 29. Huang RL. Primary Exploration of Infection Control Practices for Intradermal, Pursuing Immunization Insurance System Subcutaneous, and Intramuscular Needle in Chenghai County[J].Chinese Rural Injections, 1999. Health Service Administration, 1991 (1139-41. 38. Simonsen, L., Kane, A., LIoyd, J. and Kane, M. Unsafe Injections in The 30. Liu LQ,Jiang ZH,Wang XY. Developing World and Transmission of Immunization Insurance System Is An Blood Borne Pathohens: A Review. Important Measure to Confirm the Harvest Bulletin of the World Health Organization, of Planning Immunization[J]. Chinese 1999, 77:789-800. Journal of Epidemiology, 1997186 181-183. 39. The World Health Organization. Fact Sheet: Injection Safety. Fact sheet No. 231, 2002. 37 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 40. Hutin, Y., Chen, R.T. Injection Safety: 42. The World Health Organization. A Global Challenge. Bulletin of the World Improving Immunization Safety in the Health Oganization. 1999, 77: 787-788 Region. Combating Communicable Diseases, Geneva. 41. Miller, M., Pisani, E. The Cost of Unsafe Injections. The Bulletin of the 43. Maher, C. Progress in Improving the World Health Organization. 1999, Safety of Injections in the EPI Western 77:808-811. Pacific Region. 1998, WHO/EPI/ TECHNET.98/WP.20. 38 Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Annex 1 Question Guide For Interviewing Key Informants 1. About the Financing of · What are the mostly likely Immunization Services additional sources of financing (government, and user fees)? · What are the policies for financing each component of the · Which sources of financing inputs (vaccine, disposable would you recommend in order to syringes, capital, labor, and other) assure adequate immunization for immunization? coverage? · What are the problems in financing immunization? 2. About the Prediction of Immunization Coverage · What do you think about the association between charges (user In our study, the term "immunization fees) and the use of immunization coverage" takes into account three services? categories of children: the proportion of · What solutions would you like to children who are fully immunized using standard procedure out of the total number recommend for the problems you who need immunizations; the proportion identified? of children who receive only some of all · Do you think providers are required vaccinations; and the proportion reasonably (adequately) of children who are given unnecessary reimbursed for the immunization immunization vaccinations or more than services they provide? the required doses. Could you please predict coverage for each antigen in the · If reimbursement is inadequate, table below, using our definition of which inputs are not being immunization coverage? (Classify covered (vaccine, disposable coverage by three levels of economic syringes, capital, labor, and development: advanced, middle, and other)? undeveloped). Programs 2003 2004 2005 2006 2007 2008 2009 2010 BCG DTP Measles DT JE Hepatitis B Meningococcal -A.1.1- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 3. About the viability of disposal he or she is interviewing you. Please do methods for used injection not hesitate to ask if you have any materials problems understanding. When judging the viability of a method of Once you are certain you understand the disposing of used injection material, meaning of the variables determining consider the following five criteria: (i) viability, please give one point to the most costs; (ii) community safety; (iii) health viable method and five points to the least care provider safety; (iv) environmental viable method. And please give points to regulations; and (v) acceptability to health other methods accordingly (the fewer the care providers. The interviewer will points, the more viable the method). explain the criteria in greater depth when Burial Safety Box Burning Disinfection/ Recycling Destruction -A.1.2- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Annex 2 Review of EPI Health Insurance System Tables A2-1 and A2-2 summarize the systems for vaccines, accounted for 20% major findings from the literature review or less of expenditures in eight of the regarding the EPI prepayment scheme. In studies. Two studies indicate that 40% of the literature, the premiums varied by total insurance expenditures were used in study site and year, ranging from 7.5 to the purchase of materials. Large 115 yuan. differences in reimbursement were found between the studies. Ten of the 14 studies Table A2-1 shows the distribution of EPI state that reimbursement of enrollees insurance expenditures on major service accounted for around 20% of total items. Nine of the 14 studies report that expenditures. Other studies show a very labor costs constituted 25% or less of small proportion of expenditures being expenditures. In Taining of Fujian dedicated to reimbursement. In 9 of the 14 Province, 64% of expenditures went to study sites, a surplus fund amounting to labor costs. Materials, including injection about 20% of insurance expenditures materials and maintenance of cooling existed. Table A2-1: Level of Premium Collected for EPI Prepayment Scheme (yuan) Study sites Time Premium Ref. Henan 1988 16 [1] Dafeng, Jiangsu 1993 28 [2] Pei county, Jiangsu 1994 30 [3] Qingyang, Anhui 1996 32 [4] Sunite, Neimeng 1996 115 [5] Nanhai, Guangdong 1997 85 [6] Chenghai, Guangdong 1991 25 [7] Changping, Beijing 1995 30 [8] Huaiyin, Jinan 1998 35 [9] Lushan, Shandong 1994 4/per vaccine [10] Lanxi, Zhejiang 1992 7.5 [11] Fenghua, Zhejiang 1991 20 [12] Taining, Fujian 1995 28 [13] Guilin, Guanxi 1998 30 [14] Table A2-2: Distribution of EPI Insurance Expenditures (%) Study sites Labor Materials Other Operating Reimburse Surplus Ref. Linyungang 48 12 8 12 20 [15] Dafeng 11.17 40.12 22.70 0.52 25.01 [2] Zuzhou 25.90 15.61 22.83 1.38 34.28 [16] Rugao 25 18 17 20 20 [17] Zhongshan 23.33 33.33 10 33.33 -- [18] Chenghai 21 35 14 30 -- [7] Wangyuan 42 20 18 20 -- [19] Ranxi 25 40 5 20 10 [12] Fenghua 24 20.2 18 15 22.8 [13] Songjiang 19 19.5 18 23.5 20 [20] Changping 17.36 11.86 5.15 0.024 66.60 [9] Huaining 30 30 25 15 -- [21] Taining 64 25 11 -- -- [14] Guipin 20 20 25 15 20 [14] -A.2.1- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? References 9. Meng X.J., Fang Z. Z., Zang SB. Applying Immunization Insurance System 1. Zhang MC, Zhu B. The Content and and Promoting the Quality of Our Job Assessment of Immunization Insurance Thoroughly[J]. Modern Preventive System[J].Chinese Health Economics, Medicine, 1998253358-359. 1989652-54. 10. Zhang X. Q., Pu Z. L. ,Zou Y.X., etc. 2. Yuan LT, Yu J.C., Qin, C.K. The State Analysis of Immunization Insurance Management and Benefit Evaluation of System in Rushan County[J]. Literature Immunization Insurance Fund in Dafeng and Information of Preventive Medicine, County[J]. Jiangsu Preventive Medicine, 199954:394. 1994238-39. 11. Zhao X. J., Du J.L. The 3. Gao, Y. The Problem and Solution of Administration and Usage of Compensation After Pursuing Immunization Insurance Fund[J]. Chinese Immunization Insurance System[J]. Journal of Public Health Mangement: Jiangsu Preventive Medicine, 19941 Supplement, 1992,8(A08)32,28. 22-23. 12. Xu Y. F., Cao Y. S., Tian W, etc. 4. Bao, L.B. The Analysis of Primary Exploration of Using Children Relationship between Immunization Immunization Insurance Fund Insurance System and Immunization Reasonably[J]. Chinese Journal of Public Coverage Rate of Four Kind of Vaccines Health Management, 199174231-232. in Chengdong Town of Qingyang County[J].Anhui Preventive Medicine, 13. Yao Y., Xie Z. L. ,Zheng F., etc. The 19962476. Effect Appraisal of Practicing Immunization Insurance System in 5. Wang X., Tian Y.B. Some Taining County[J]. Strait Journal of Experience of Pursuing Immunization Preventive Medicine, 19951148-49. Insurance System[J]. Neimenggu Preventive Medicine, 1997223 14. Luo L.B.,Huang Y. N., Zhang Q. Z. 133-134. The Effect of Pursuing Children Immunization Insurance System in Guilin 6. http://www.gdaw.gov.cn/new/fzgh/f5. City[J]. Guangxi Preventive htm Medicine,199955297-298. 7. Huang R. L. Primary Exploration of 15. Hao J. H. The Effect Observation of Pursuing Immunization Insurance System Pursuing Children Immunization in Chenghai County[J].Chinese Rural Insurance System in City Zone[J]. Health Service Administration, 1991 Occupational Health and Emergency 1139-41. Rescue, 1997152101-102. 8. Liu L.Q., Jiang Z. H., Wang X.Y. 16. Liu J., Hu C. F., Bai Z. Y. Immunization Insurance System Is An Compensation Status Analysis of Important Measure to Confirm the Harvest Immunization Insurance System in of Planning Immunization[J]. Chinese Xuzhou City. Jiangsu Preventive Medicine, Journal of Epidemiology, 1997186 1997254-55. 181-183. -A.2.2- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 17. Xu X. Y. ,Ren Z. L. ,Li X. D. 20. Shen S. L. ,Zhang Z.C. The Modus Operandi and Effect of Enforcing Exploration and Practice of Planning Children Immunization Insurance System Immunization[J]. Chinese Primary Health Management in Rugao County. Chinese Care, 199913331-33. Primary Health Care, 1996,10(5):33. 21. Hu H. W., Xu H., Li Q. The 18. Zhao W. Y .The Experience of Discussion of Immunization Insurance Practicing Children Immunization System's Result in Huaining Insurance System[J]. Chinese Journal of County[J].Anhui Preventive Medicine, Vaccines and Immunization, 199512 199952203-20. 38. 19. Deng H., He Z. Z. How to Administrate and Use Immunization Insurance Fund Efficiently[J]. Chinese Primary Health Care, 199610140. -A.2.3- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Annex 3 Documented Situation of Injection Safety Nine studies were examined for the Table A3-2 presents methods of purpose of describing the types of syringes disinfecting reusable syringes based on used, as summarized in Table A3-1. The nine (9) studies. In rural areas, the following impressions were gathered from proportion of health facilities using the those studies: boiling method for disinfection was higher than in urban areas in general. In Shanxi Time effect. Even though there were and Shaanxi, more than 60% of the rural no cohort studies available for health facilities studied used the boiling mapping changes over time in the method in 1998. In Wulong county of type of syringe used, it seems that Chongqing City, nearly 80% of health reusable (glass) syringes are facilities still used the boiling method for increasingly being replaced by syringe disinfection in 2002. In a study of disposable syringes. In Anhui, a five western provinces in 2000, more than mid-income province, 12% of rural 20% of health facilities wiped the needles health facilities in the study used with an alcohol solution while more than only disposable syringes in 1996. In 10% of health facilities disinfected the Shaanxi, a poorer province, 21% of needles by washing them with water. rural health facilities used only disposable syringes in 2000; Nine studies on methods of destroying disposable syringes are summarized in Geographic variation. It seems that Table A3-3. All the studies for 1999, study sites in the wealthier except in Gansu, reported burning a high provinces used a higher proportion proportion of disposable syringes and of disposable syringes than less needles. However, there was no report on wealthy provinces during the same burial after burning. It was noted that time period. In 1999, the study in more than 80% of health facilities studied Liaoning reported that 80% of in Gansu, and nearly 26% of health health facilities were using only facilities studied in Liaoning, simply threw disposable syringes for away disposable injection material after immunization services, while Gansu, use, without taking any measures to a poorer western province, reported disinfect and destroy material (1999). only 3% of health facilities using Studies in 2000 reported an increase in the disposable syringes for proportion of disposable injection material immunization programs; and that was buried. Recycling was also seen in about 20% of township health facilities Wider use of disposable syringes for in the five western provinces. In 2001 and immunization services. In most of 2002, the studies in Henan and Wulong of the studies that included both Chongqing indicated that a high immunization and therapeutic proportion of health facilities in rural areas services, disposable syringes were threw away disposable injection materials. far more likely to be used for immunization services than for therapeutic services. -A.3.1- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table A3-1: Proportions of Syringes used for Immunization/Therapeutic Services Study Sites Time Location Service Proportion % Ref. Disposable Reusable Mixed Anhui 1996 Rural Immu. 12.12 51.52 36.36 [1] Shanxi 1998 Urban Immu. 92.00 8.00 -- [2] Therap. 67.70 32.30 -- Rural Immu. 72.81 27.19 -- Therap. 46.37 53.63 -- Hubei 1999 Village Immu. 26.37 14.29 59.34 [3] Township 13.33 6.67 80.00 Town 57.14 0 42.86 Liaoning 1999 Rural Immu. 80.49 0 19.51 [4] Gansu 1999 Urban Immu. 61.3 6.5 32.2 [5] Rural 3.03 28.28 68.69 Fujian 1999 Rural & Immu. 72.5 7.5 20.0 [6] Urban Sichuan 1999 Rural & Immu. 45.64 54.36 [7] Urban Shaanxi 2000 Rural Immu. 21.2 24.0 54.8 [8] Therap. 24.2 16.8 59.0 Shanxi, 2000 Village Immu. 15.6 32.9 51.5 [4][9] Shaanxi, Therap. 16.5 30.7 52.8 Gansu, Township Immu. 64.4 7.9 27.7 Qinghai, Therap. 49.3 11.7 39.0 Ningxia Rural and Urban (R & U) Table A3-2: Methods of Disinfection for Reusable (Glass) Syringes Study sites Time Location Proportion % Ref. Steamed Boiling Alcoholic Washing Anhui 1996 Rural 62.5 37.5 0 0 [1] Hebei 1997 Rural 25.4 73.0 0 1.6 [10] Shanxi 1998 Urban 91.69 8.31 0 0 [2] Rural 36.04 62.77 0 1.19 Henan 1998 Rural 26.4 69.4 4.2 0 [11] Fujian 1999 Rural & 75.8 24.2 0 0 [6] Urban Gansu 1999 Urban 80.6 19.4 0 0 [12] Rural 77.8 19.0 0 3.1 Shanxi, 2000 Township 77.0 15.0 20.4 9.7 [9] Shaanxi,Gansu, Village 77.8 41.7 23.1 12.4 Qinghai, Ningxia Hubei 2001 Rural 77.78 22.22 0 0 [3] Chonqing 2002 Rural 21.7 78.3 0 0 [13] -A.3.2- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table A3-3: Methods of Destruction of Disposable Syringes Study Sites Time Location Proportion % Ref. Burning Burial D/D Recycling Reuse Throw Hubei 1999 Rural & 65.00 5.83 25.83 [14] Urban Fujian 1999 Rural & 91.89 7.21* 0.83 [6] Urban Liaoning 1999 Village 100.0 0 0 0 0 [4] Gansu 1999 Rural & >80.0 [12] Urban Shaanxi 2000 Rural 73.8 66.1 47.5 6.3 1.3 18.9 [8] Ningxia 2000 Urban 76 24 [15] Shanxi, 2000 Township 64.9 27.2 42.4 21.0 0 13.6 Shaanxi, Village 55.4 33.3 28.6 3.9 2.7 21.3 [9] Gansu, Qinghai, Ningxia Henan 2001 Urban 6.67 0 86.67 0 0 6.67 [16] Rural 17.61 7.04 0 0 0 75.35 Chongqing 2002 Rural 27.3 6.1 0 3.0 0 63.6 [13] Rural and Urban (R & U); Disinfection/Destruction (D/D) -A.3.3- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? References 352-355. 1. Shen YG, He ZM. An Investigation On 9. Li YX.Investigation on Current Status the Safety of Injection in Immunization Service in Partial Rural Areas of Anhui of Safe Injection of Preventive Inoculation Province. Chinese Journal of Vaccines and in Five Provinces of Western China and Immunization; 1998, 4 (30) : 159-160. the Affecting Factors. Chinese Journal of Vaccines and Immunization; 2002, 8 (6) : 2. Zhang JS, M ZQ. Investigation On Safe Injection Status of Medical and Preventive 241-243. Organizations in Shanxi (the capital is Taiyuan) Province. Journal of Preventive 10. Cao YH, Li LJ. Investigation on Medicine Information; 2001, 17 (3) : Medicine and Immunization Injection 174-176. Status in Rural Areas of Zunhua City. Chinese Journal of Vaccines and 3. Jiang XQ. Investigation on Safe Injection Status of 120 Urban and Rural Immunization; 1997, 3 (5) : 231. Grass-roots EPI Immunization Spots in Hubei Province. Chinese Journal of 11. Nie ZP. Analysis on the Safety Vaccines and Immunization; 2002, 4, 8 Injection Status of EPI Immunization of (2) : 95-97. Puyang City. Chinese Primary Health Care; 1999, 13 (4) : 39. 4. Pang FS. An Investigation On the Safety of Injection in Immunization 12. He DP. Evaluation on the Quality of Service in Partial Rural Areas of Liaoning Immunization Service in Dingxi Areas in Province. Chinese Journal of Vaccines and 2001. Chinese Medical Theory and Immunization; 2000, 6 (3) : 157-159. Practice. Chinese Journal of Vaccines and Immunization; 2002, 2002 (4) : 517-518. 5. Li H, He GS, C FQ. An Investigation on Present Situation of Safe Injection of 13. Li Q, Ou JM, etc. Investigation On Immunization Service in Different Safe Injection Status of Medical Economic Areas in Gansu Province. Organizations in Wulong County in Chinese Journal of Vaccines and Chongqing Ciy. Chinese Journal of Immunization; 2001, 7 (4) : 218-220. Epidemiology; 2003, 24 (3) : 176-179. 6. Yang Y, Zhou Y, etc. Present Situation 14. Jiang XQ. Investigation on Safe Injection Status of 120 Urban and Rural and Affecting Factors of Safe Injection in Grass-roots EPI Immunization Spots in Immunization Program In Fujian Province. Hubei Province. Chinese Journal of Chinese Journal of Vaccines and Vaccines and Immunization; 2002, 4, 8 Immunization; 2002, 8 (3). (2) : 95-97. 15. Zhao R, Huang GM. Investigation on 7. Liu QL, Fang G, etc. An Analysis on the Safety Injection Status of Immunization Safety Injection in Immunization Service Service in Three Districts of Shizuishan in Sichuan Province. Modern Preventive City. Journal of Ningxia Mecical College. Medicine; 2001, 28 (1) : 51-52. 2001, 23 (5) : 359-360. 8. Xia XQ, He HL, etc. Analysis on the 16. Zhang YH. An Investigation on the Safety Injection Status of EPI Investigation of Safety Injection Status of Immunization of Grass-roots of Puyang Rural Grass-roots in Shanxi (the capital is City in Henan Province. Chinese Journal Xi'an) Province. Chinese Journal of of Epidemiology; 2003, 24 (3) : 175. Vaccines and Immunization; 2001, 7 (6) : -A.3.4- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Annex 4 Reported and Actual Coverage of Immunization Programs 1. The present situation in the country for the four kinds of vaccines were all as a whole above 97% in 1990, 1999 and 2001. According to the data from China's Health This is not the case, however, as can be Ministry, the reported coverage rate for seen in Table A4-2. If we look at OPV, for four kinds of vaccines included in routine example, we find that actual immunization immunization is summarized in Table coverage rates in different provinces were A4-1. between 50% and 96.8% from 1997 to 2001 (inferred from the immunization Table A4-1 seems to indicate that except information of children supplied by the for in 1995, immunization coverage rates AFP Inspecting System). . Table A4-1: Summary of Reported Routine Immunization Coverage Rate in China (%) 1990 1995 1999 2001 BCG 99 92 98 98 OPV 98 94 98 98 DPT 97 92 97 98 MV 98 93 98 98 Data Source: [1]. Table A4-2: Distribution of Actual Immunization Coverage Rate of OPV, 1997- 2001 Actual Immunization Province Coverage Rate% 0~60 Neimenggu, Xizang, Yunnan, Hubei, Jiangxi 60~70 Xinjiang, Guizhou, Hunan, Guangxi, Chongqing 70~80 Qinghai, Shaanxi (the capital is Xi'an), Henan, Ningxia 80~90 Gansu, Hainan, Guangdong, Fujian, Zhejiang, Liaoning, Anhui, Shanxi (the capital is Taiyuan), Heilongjiang 90~100 Beijing, Tianjin, Hebei, Shandong, Jiangsu, Jilin Data Source: [2]. -A.4.1- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? 2. The Difference between Reported routine immunization made by the Immunization Coverage Rate and Departments for Disease Control and Actual Immunization Coverage Prevention in some provinces. The data on Rate among Some Provinces population and birthrate are from the local statistics department or the local Police. In In China the data gotten through Guizhou the birthrate data is obtained monitoring and evaluation of reported through spot checks. In Fujian, the effect immunization coverage rates are very rich. of children of the floating population is In order to further compare reported taken into consideration when the actual coverage rates with actual coverage rates, coverage rate is computed. we provide in Table A4-3 a summary of data from some typical provinces. The main causes for the difference between reported coverage rates and the The data on Reported Coverage Rates actual coverage rates include: (RCR) are drawn from the report forms on Table A4-3: Comparison between Reported Routine Immunization Coverage Rate and Actual Immunization Coverage Rate in Some Provinces (%) Province Year Immunization Programs Ref. BCG OPV DPT MV HBV Neimeng 1999 RCR 98.47 98.70 98.56 98.45 97.6 [3] ACR 62.87 71.03 70.08 68.81 51.23 Gap 36 27 28 30 46 Hubei 2000 RCR 98.92 97.61 97.17 96.76 86.55 [4] ACR 51.10 62.72 62.01 64.12 28.63 Gap 48 35 35 29 58 Guizhou 1999 RCR 94.9 98.4 96.3 98.1 89.5 [5] ACR 70.2 76.9 72.9 83.7 6.6 Gap 25 22 23 14 83 Hunan 2000 RCR 97.5 97.1 96.9 96.6 - [6] ACR 80.1 79.8 79.6 79.3 - Gap 17 17 17 17 - Hainan 2000 RCR 94.63 96.33 95.92 93.37 - [7] ACR 92.55 91.66 88.76 83.36 - Gap 2 5 7 10 - Zhejiang 1999 RCR 97.6 98.0 97.4 97.1 - [8] ACR 78.8 82.7 83.4 82.7 - Gap 19 15 14 14 - Liaoning 1999 RCR - 99.2 100.8 100 99.8 [9] ACR - 89.0 89.5 88.1 73.5 Gap - 10 11 12 26 Anhui 1998 RCR 90.5 94.9 95.1 92.7 90.2 [10] ACR 63.4 79.0 75.1 85.0 13.7 Gap 27 16 20 8 77 Fujian 2001 RCR 96.9 98.1 98.3 97.2 97.8 [11] ACR 95.7 96.4 95.4 95.6 90.4 Gap 1 2 3 2 7 Reported Coverage Rate (RCR); Actual Coverage Rate (ACR). -A.4.2- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? The population that should be source material from towns and immunized according to the villages. This type of grass roots Immunization Planning Depart- data can be affected by subjective ment's figures is different from the factors such as failing to report all birth population given by the local cases or fabricating false reports. statistics department or the local Police. The method currently used to compute actual immunization China's system of monitoring coverage rates is somewhat routine immunizations depends on flawed. -A.4.3- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? References Medicine; 2001, 8(4): 283-284. 1. Chinese Health Ministry, Chinese 7. Shi JR, Sun LY, etc. Monitoring the Health Statistics Abstract, 2002. Status and Quality of the Report on Conventional Immunization Program in 2. Zuo SY, Wang XJ, etc. Qulatiy of Hainan Province in 2000. China Tropical Reports of Routine Immunization Medicine; 2002, 2(3): 401-403. Coverage and Its Affecting Factors. Chinese Journal of Vaccines and 8. Ling LY, Li Q, etc. Analysis on Running Immunization; 2002, 8 (6): 337-340. Effect of the Surveillance System on EPI Routine Immunization in Zhejiang 3. Wang HX, Li ZZ etc. Situation and Province. Chinese Journal of Vaccines and Evaluation on Reports of the Routine Immunization; 2001, 7(3): 168-170. Immunization Coverage Rate in Huhehaote City. Chinese Journal of 9.Yu HJ, Yao WQ, etc. Analysis on New Vaccines and Immunization; 2001, 7(5): and Old Scheme in Liaoning Province. 4.Cheng SQ, ZH JS, etc. The Inspecting Chinese Journal of Vaccines and Report of Routine Immunization in Hubei Immunization; 2001, 7(6): 355-358. Province in 2000. Hubei Journal of Preventive Medicine; 2001, 12(4): 2-4. 10. Lu ZJ, Sheng YG, etc. Evaluation on the Routine Immunization Reporting 5.Zhou H, Zhu Q, etc. The Inspecting System in Anhui Province in 1998. Evaluation of Routine Immunization Chinese Journal of Vaccines and Coverage Rate in Guizhou in 1999. Immunization; 2000, 6(2):101-104. Chinese Journal of Vaccines and Immunization; 2000, 6(5): 273-275. 11.Cheng QP, Liu WH, etc. Analysis on Running Effect of the Surveillance System 6. Xie C, Li F, etc. Quality Evaluation on on EPI Routine Immunization in Longyan Reports of Routine Immunization City. Literature and Information of Coverage Rate in Hunan Province and Its Preventive Medicine; 2002, 8(6):703-704. Influencing Factors. Practical Preventive -A.4.4- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Annex 5 Projected Numbers of Children, Injections, and Costs Table A5-1: Projected Number of Children Below 7 Years of Age (million) 2004 2005 2006 2007 2008 2009 2010 TOTAL 123.8 124.7 125.6 126.5 127.4 128.4 129.3 Beijing 1.0 1.0 1.0 1.0 1.0 1.0 1.0 Tianjin 0.8 0.8 0.8 0.8 0.8 0.8 0.8 Shanghai 1.2 1.2 1.2 1.2 1.2 1.2 1.2 Jiangsu 6.1 6.1 6.1 6.2 6.2 6.2 6.2 Zhejiang 4.2 4.2 4.3 4.3 4.3 4.3 4.3 Shandong 8.5 8.5 8.5 8.6 8.6 8.7 8.7 Guangdong 9.4 9.5 9.6 9.7 9.8 9.9 10.0 Hebei 6.5 6.6 6.6 6.7 6.7 6.8 6.8 Shanxi 3.6 3.7 3.7 3.7 3.8 3.8 3.9 Liaoning 3.5 3.5 3.6 3.6 3.6 3.6 3.6 Jilin 2.2 2.2 2.2 2.2 2.3 2.3 2.3 Heilongjiang 3.1 3.1 3.1 3.1 3.2 3.2 3.2 Anhui 5.9 6.0 6.0 6.1 6.1 6.2 6.2 Fujian 3.1 3.1 3.1 3.1 3.2 3.2 3.2 Jiangxi 4.6 4.6 4.7 4.7 4.8 4.8 4.9 Hubei 5.0 5.0 5.1 5.1 5.1 5.1 5.2 Hunan 5.9 5.9 6.0 6.0 6.0 6.1 6.1 Hainan 0.9 0.9 0.9 0.9 0.9 0.9 0.9 Chongqing 3.1 3.1 3.1 3.1 3.2 3.2 3.2 Sichuan 8.5 8.6 8.6 8.7 8.7 8.8 8.9 Xizang 0.4 0.4 0.4 0.4 0.4 0.4 0.4 Neimenggu 2.2 2.2 2.2 2.3 2.3 2.3 2.3 Henan 9.3 9.4 9.5 9.5 9.6 9.7 9.8 Guangxi 4.8 4.8 4.8 4.9 4.9 5.0 5.0 Guizhou 5.0 5.0 5.1 5.2 5.2 5.3 5.4 Yunnan 5.4 5.4 5.5 5.6 5.6 5.7 5.8 Shaanxi 3.4 3.4 3.4 3.4 3.4 3.5 3.5 Gansu 2.8 2.8 2.8 2.8 2.9 2.9 2.9 Qinghai 0.6 0.6 0.6 0.6 0.6 0.6 0.7 Ningxia 0.7 0.7 0.7 0.7 0.7 0.8 0.8 Xinjiang 2.2 2.2 2.3 2.3 2.3 2.3 2.4 -A.5.1- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table A5-2: Projected Numbers of Injections for Defined Immunization Program (million) 2004 2005 2006 2007 2008 2009 2010 TOTAL 148.61 155.44 167.7 175.01 187.57 197.73 211.27 Beijing 1.22 1.25 1.29 1.34 1.39 1.44 1.53 Tianjin 1.01 1.04 1.07 1.12 1.16 1.20 1.28 Shanghai 1.38 1.41 1.45 1.51 1.56 1.62 1.71 Jiangsu 7.95 8.18 8.45 8.83 9.16 9.54 10.17 Zhejiang 5.96 6.14 6.36 6.64 6.90 7.18 7.67 Shandong 12.05 12.41 12.87 13.45 13.98 14.57 15.57 Guangdong 12.80 13.24 13.79 14.49 15.13 15.85 17.02 Hebei 7.93 8.38 8.83 9.30 10.12 10.56 11.37 Shanxi 4.49 4.76 5.04 5.32 5.81 6.08 6.57 Liaoning 3.99 4.20 4.39 4.61 4.99 5.19 5.56 Jilin 2.55 2.69 2.82 2.97 3.22 3.35 3.60 Heilongjiang 3.42 3.60 3.77 3.97 4.30 4.48 4.81 Anhui 7.19 7.61 8.03 8.48 9.24 9.66 10.42 Fujian 3.68 3.88 4.08 4.29 4.66 4.85 5.21 Jiangxi 6.02 6.38 6.76 7.13 7.81 8.17 8.83 Hubei 5.49 5.78 6.05 6.38 6.89 7.18 7.71 Hunan 7.14 7.52 7.90 8.31 9.02 9.39 10.09 Hainan 1.12 1.19 1.26 1.33 1.46 1.53 1.66 Chongqing 3.45 3.64 3.81 4.01 4.34 4.52 4.85 Sichuan 9.67 10.20 10.71 11.30 12.26 12.79 13.76 Xizang 0.50 0.54 0.57 0.61 0.67 0.71 0.77 Neimenggu 2.20 2.29 2.66 2.72 2.91 3.14 3.31 Hennan 10.26 10.71 12.50 12.78 13.76 14.85 15.67 Guangxi 5.18 5.40 6.31 6.45 6.94 7.50 7.91 Guizhou 5.61 5.89 6.94 7.14 7.74 8.41 8.93 Yunnan 6.18 6.48 7.61 7.82 8.46 9.16 9.71 Shaanxi 3.31 3.45 3.99 4.07 4.35 4.70 4.94 Gansu 2.96 3.09 3.61 3.70 3.98 4.31 4.55 Qinghai 0.66 0.70 0.82 0.84 0.91 0.99 1.05 Ningxia 0.78 0.82 0.96 0.99 1.07 1.16 1.23 Xinjiang 2.44 2.56 3.00 3.08 3.33 3.60 3.82 -A.5.2- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Table A5-3: Projected Cost of Disposable Syringes (million yuan) 2004 2005 2006 2007 2008 2009 2010 TOTAL 49.0413 55.9584 65.403 73.5042 84.4065 96.8877 111.9731 Beijing 0.4026 0.45 0.5031 0.5628 0.6255 0.7056 0.8109 Tianjin 0.3333 0.3744 0.4173 0.4704 0.522 0.588 0.6784 Shanghai 0.4554 0.5076 0.5655 0.6342 0.702 0.7938 0.9063 Jiangsu 2.6235 2.9448 3.2955 3.7086 4.122 4.6746 5.3901 Zhejiang 1.9668 2.2104 2.4804 2.7888 3.105 3.5182 4.0651 Shandong 3.9765 4.4676 5.0193 5.649 6.291 7.1393 8.2521 Guangdong 4.224 4.7664 5.3781 6.0858 6.8085 7.7665 9.0206 Hebei 2.6169 3.0168 3.4437 3.906 4.554 5.1744 6.0261 Shanxi 1.4817 1.7136 1.9656 2.2344 2.6145 2.9792 3.4821 Liaoning 1.3167 1.512 1.7121 1.9362 2.2455 2.5431 2.9468 Jilin 0.8415 0.9684 1.0998 1.2474 1.449 1.6415 1.908 Heilongjiang 1.1286 1.296 1.4703 1.6674 1.935 2.1952 2.5493 Anhui 2.3727 2.7396 3.1317 3.5616 4.158 4.7334 5.5226 Fujian 1.2144 1.3968 1.5912 1.8018 2.097 2.3765 2.7613 Jiangxi 1.9866 2.2968 2.6364 2.9946 3.5145 4.0033 4.6799 Hubei 1.8117 2.0808 2.3595 2.6796 3.1005 3.5182 4.0863 Hunan 2.3562 2.7072 3.081 3.4902 4.059 4.6011 5.3477 Hainan 0.3696 0.4284 0.4914 0.5586 0.657 0.7497 0.8798 Chongqing 1.1385 1.3104 1.4859 1.6842 1.953 2.2148 2.5705 Sichuan 3.1911 3.672 4.1769 4.746 5.517 6.2671 7.2928 Xizang 0.165 0.1944 0.2223 0.2562 0.3015 0.3479 0.4081 Neimenggu 0.726 0.8244 1.0374 1.1424 1.3095 1.5386 1.7543 Henan 3.3858 3.8556 4.875 5.3676 6.192 7.2765 8.3051 Guangxi 1.7094 1.944 2.4609 2.709 3.123 3.675 4.1923 Guizhou 1.8513 2.1204 2.7066 2.9988 3.483 4.1209 4.7329 Yunnan 2.0394 2.3328 2.9679 3.2844 3.807 4.4884 5.1463 Shaanxi 1.0923 1.242 1.5561 1.7094 1.9575 2.303 2.6182 Gansu 0.9768 1.1124 1.4079 1.554 1.791 2.1119 2.4115 Qinghai 0.2178 0.252 0.3198 0.3528 0.4095 0.4851 0.5565 Ningxia 0.2574 0.2952 0.3744 0.4158 0.4815 0.5684 0.6519 Xinjiang 0.8052 0.9216 1.17 1.2936 1.4985 1.764 2.0246 -A.5.3- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Annex 6 List of Chinese Experts Involved in the Study Yu Jingjin, Department of Disease Control, Ministry of Health Cui Gang, Department of Disease Control, Ministry of Health Lei Zhenglong, Department of Disease Control, Ministry of Health Feng Zijian, NIP Officer Wang Xiaojun, GAVI Project Office Hao Lixin, NIP Office Guo Biao, NIP Office Li Yixing, NIP and JICA Officer Xu Aiqiang, Shandong CDC Song Lizhi, Shandong CDC Zhang Li, Shandong CDC Jiang Fei, Shandong CDC Huang Daliang, Shandong Jinan Municipal CDC Xiong Xiaoqing, Shandong Jinan Municipal CDC Qi Laifeng, Shandong Jinan Municipal CDC Ma Donghui, Shaanxi Department of Disease Control Zhang Feng, Shaanxi CDC -A.6.1- Making Injections Safe in China: How Much Will It Cost and Who Will Pay? Working Papers Human Development Sector Unit The World Bank No. 2004-1: Disability Issues in East Asia: Review and Ways Forward No. 2004-2: Cambodia Skills and Growth No. 2004-3: Evaluating the Performance of SGP and SIGP: A Review of the Existing Literature and Beyond No. 2004-4: Vietnam Reading and Mathematics Assessment Study ­ Volume 1 No. 2004-5: Addressing Inequity in Access To Health Care in Urban China: A Review of Health Care Financing Reform Experiments No. 2004-6: Strengthening World Bank Support for Quality Assurance and Accreditation in Higher Education in East Asia and the Pacific No. 2004-7: Financing Health Care for Poor Filipinos No. 2004-8: Health Care Financing for the Poor in Vietnam No. 2004-9: Pro-Poor Health Financing Schemes in Thailand: A Review of Country Experience No. 2004-10: Health Financing for the Poor in Indonesia