Public Disclosure Authorized The World Bank Hainan Health Sector Reform Project (P171064) Rapid Poverty and Social Impact Assessment

Public Disclosure Authorized

Public Disclosure Authorized

Hainan health commission December 2019 Public Disclosure Authorized

0 Contents 1 Background ...... 3 1.1 Project Overview ...... 3 1.2 Components ...... 3 1.3 Purpose ...... 4 1.4 Methods ...... 4 2 Socioeconomic Profile of Hainan Province ...... 5 2.1 Population and Distribution ...... 5 2.2 Economic Situation ...... 6 2.3 Health and Medical Care ...... 6 3 Stakeholder Needs ...... 7 3.1 Stakeholder Identification ...... 7 3.2 Stakeholder Attitudes and Needs ...... 8 3.3 Social Benefits of the Project ...... 9 4 Project Impacts on Poor People ...... 10 4.1 Poor People of Hainan Province ...... 10 4.2 Medical Services of Poor People ...... 10 4.3 Project Impacts on Poor People ...... 13 5 Project Impacts on Migrant Population ...... 14 5.1 Current Situation of Migrant Population ...... 14 5.2 Health and Medical Care of Migrant Population ...... 14 5.3 Project Impacts on Migrant Population ...... 15 6 Project Impacts on Women ...... 16 6.1 Women’s Health Status ...... 16 6.2 Use of Primary Healthcare by Women ...... 16 6.3 Women’s Health Program ...... 17 6.4 Project Impacts on Women ...... 17 7 Project Impacts on Minority Population ...... 19 7.1 Minority Population ...... 19 7.2 Health and Medical Care of Minority Population ...... 20 7.3 Minority Health Program ...... 20 7.4 Project Impacts on Minority Population ...... 20 8 Conclusions and Suggestions ...... 22 8.1 Conclusions ...... 22 8.1.1 The Project is beneficial to all stakeholders and does not exclude vulnerable groups. ... 22 8.1.2 Migrant population will not occupy local residents’ medical resources...... 23 8.2 Suggestions ...... 24 Appendix 1 Statistics of Workforce of Township Health Centers in Hainan Province and Sample Cities / Counties ...... 27 Appendix 2 Summary of Stakeholder FGDs ...... 27 Appendix 3 Flowchart of Priority Medical Care for Registered Poor Patients ...... 29 Appendix 4 Fieldwork Photos...... 30 Table 2-1 Population Statistics of Hainan Province (2017)...... 5 Table 3-1 Primary Stakeholders ...... 7 Table 3-2 Analysis of Stakeholder Attitudes and Needs ...... 8 Table 4-1 Summary of Health Poverty Alleviation in Hainan Province...... 11 Table 7-1 Populations and Features of Main Ethnic Minorities in Hainan Province ...... 19 Figure 4-3 Green Channel for Medical Care of Poor Patients……………………………………. 12

Abbreviations

EAC - Ethnic Affairs Commission FDT - Family Doctor Team FGD - Focus Group Discussion HC - Health Commission HHDRC - Hainan Health Development Research Center HHSA - Hainan Healthcare Security Administration HPHC - Hainan Provincial Health Commission HSA - Healthcare Security Administration PAO - Poverty Alleviation Office PHC - Primary Healthcare PMO - Project Management Office SEP - Stakeholder Engagement Plan WF - Women’s Federation

Units

Currency unit = Yuan (CNY) USD1.00 = CNY6 1 hectare = 15 mu

1 Background 1.1 Project Overview The overall goal of the Hainan Health Sector Reform Project (HHSRP) is to strengthen the quality of primary health care (PHC) services and efficiency of the health system. Focusing on primary health care (the foundation for people-centered integrated care), the Project takes an integrated health system approach to deliver improved health outcomes for the people of Hainan. Recognizing that there is no silver bullet to achieve this goal, the project adopts a two-pronged approach:

1） The project supports the strengthening of primary care delivery system to address several key gaps that plague the health system in Hainan, including: a) poor preventive and promotive care, particularly in the context of the rising incidence of NCDs and an ageing population; b) the routine bypassing of PHC facilities in favor of hospital care; c) the declining quality of PHC, largely due to a lack of rigorously applied standards of service quality and shortage of appropriately qualified human resources; and d) inefficiencies in financing that disproportionately affect service utilization and health outcomes of the poor and most vulnerable. The central focus for PHC strengthening will be (i) to build health sector stewardship of People Centered Integrated Care (PCIC) through better integration of different levels of care and alignment of public health functions such as disease surveillance and emergency response with PHC service delivery; and (ii) to improve the performance of Family Doctor Teams (FDTs) operating in township health clinics, village clinics and community health centers through targeted strengthening of front-line service delivery , rigorous measurement of performance outputs and outcomes, supportive supervision and targeted incentives driving forward a strong/high capacity PHC system that is delivered through team-based approaches and responds efficiently to population health needs.

2）This is supported with deeper institutional, human resource, and information technology reform to create a sustainable and efficient service delivery system. At the operational level this will mean providing technical and financial support for strategic and results-oriented planning and management, evidence-based decision-making and adoption of e-governance platforms for greater coordination and efficiency. The Project will also streamline strategic purchasing of services through insurance programs in order to drive the system towards the Project goals of improving quality of primary care and efficiency of the health system. At the individual provider level, the Project will leverage incentives to change provider-level behavior and improve care for the growing burden of NCDs.

1.2 Components Component 1: Improving Primary Health Care Performance • Strengthening Stewardship of the Provincial Health Commission

3 • Strengthening Front Line Service Delivery • Upgrading PHC infrastructure Component 2: Strengthening Information Technology • The Provincial Health Commission IT Capacity • The Provincial Health Security Agency IT Capacity Component 3: Strategic purchasing for quality services Component 4: Technical Assistance

1.3 Purpose The exclusion of vulnerable groups from access to project benefits can be further assessed through a poverty and social impact assessment – as a tool for ensuring improvements to project design as part of ESMF. 1) Understand socio-economic baseline, learning all stakeholders’ needs for the Project, and the Project’s impacts on them, especially poor people and minority residents, and proposing suggestions to improve the project design; 2) Identifying the Project’s potential social risks, and proposing suggestions to evade risks; and 3) To tailor the project design to pay attention to the vulnerable groups and ethnic minorities by effective and appropriate stakeholder engagement approach to achieve the equal improvement for the poorest people and ethnic minorities population.

1.4 Methods In this rapid poverty and social impact assessment, such methods as literature review, key informant interview, FGD and field investigation were used. During September 17-22, 2019, the task force visited Baoting Li-Miao Autonomous County (no longer a poor county in 2019), Wuzhishan City (poor area, gathering of minority residents), Sanya City (gathering of migrant population) and Haikou City (gathering of migrant population). Among these cities / counties, minority population accounts for 69.5% and 73.3% in Baoting County and Wuzhishan City, respectively. Baoting County was no longer a poor county in 2019, and Wuzhishan City is still a poor area, where minority and poor populations highly overlap. Therefore, these two cities / counties are most typical in stakeholder needs (especially vulnerable groups) and rural medical care; Haikou and Sanya Cities have largest migrant populations and are more economically developed, so they are most typical in urban primary healthcare and migrant population needs.

During the fieldwork, the task force held FGDs with health commissions (HCs), ethnic affairs commissions (EACs), women’s federations (WFs), and poverty alleviation offices (PAOs) in Hainan Province and the sample cities / counties, and conducted in-depth interviews with PHC provider staff and residents to learn the basic information of PHC providers, the use of PHC services by local residents, migrants, poor people, minority residents, women and other vulnerable groups. During the fieldwork, 15 FGDs were held with 160 persons, and 88 key informant interviews conducted.

4 2 Socioeconomic Profile of Hainan Province 2.1 Population and Distribution Hainan is a tropical island in southern China, with a tropical monsoon climate, rich rainfall, and distinct dry and rainy seasons.

According to the 2018 Statistical Yearbook of Hainan Province, Hainan has 27 cities, counties and districts, including 6 autonomous counties, 8 districts and 218 townships (including sub-districts), and a resident population1 of 9.2576 million, in which male population accounts for 52.41% and urban population for 58.04%. About 8.14% of residents are aged 65 years or above, below the national average by over 3%. Hainan attracts a large migrant population from other provinces for wintering due to its tropical climate. From October 1, 2017 to April 30, 2018, the migrant population wintering in Hainan was as large as 1.65 million, in which retirees aged 60 years or above accounted for 56%.

Hainan has a minority population of 1.6574 million, accounting for 18.2%, in which Li population accounts for about 16%, followed by Miao, Zhuang, Hui, etc. The minority population is distributed mainly in Sanya and Wuzhishan Cities, and Baoting, Qiongzhong, Lingshui, Baisha and Changjiang Counties. See Table 2-1.

Table 2-1 Population Statistics of Hainan Province (2017) Residentpopulation / population(resident) Minority population Percentof minority (registered) / 0,000 populationFemale (registered) / 0,000 population 0,000 / Percent offemale Rural population (resident) / 0,000 Percentof rural (registered) (registered) Registered population population 0,000 Administrative division

Hainan Province 925.76 910.41 388.45 41.96% 434.50 47.73% 165.74 18.2% Haikou City 227.21 171.05 49.51 21.79% 83.35 48.73% 3.50 2.0% Sanya City 76.42 59.22 19.17 25.09% 29.06 49.07% 25.26 42.7% Wuzhishan City 10.65 10.58 4.55 42.72% 5.13 48.49% 7.76 73.3% Baoting County 15.19 16.78 9.19 60.50% 8.09 48.21% 11.67 69.5% Wenchang City 56.35 59.79 26.63 47.26% 29.37 49.12% 0.57 0.9% Qionghai City 51.08 51.55 25.53 49.98% 24.57 47.66% 2.02 3.9% Wanning City 57.36 62.44 28.71 50.05% 29.65 47.49% 11.01 17.6% Ding’an County 29.48 34.43 16.13 54.72% 16.01 46.50% 0.77 2.2% Tunchang County 26.67 30.77 14.36 53.84% 14.44 46.93% 3.69 12% Chengmai County 49.08 56.14 21.94 44.70% 25.73 45.83% 0.70 1.2% Lingao County 44.87 50.03 24.62 54.87% 23.78 47.53% 0.10 0.2% Danzhou City 99.33 104.16 45.73 46.04% 48.79 46.84% 9.42 9% Dongfang City 42.62 44.98 22.57 52.96% 21.28 47.31% 9.42 21% Ledong County 47.91 53.74 29.71 62.01% 25.59 47.62% 20.86 38.8% Qiongzhong County 17.89 21.62 10.70 59.81% 10.13 46.85% 13.67 63.2% Lingshui County 33.15 38.13 17.97 54.21% 18.21 47.76% 21.86 57.3% Baisha County 17.25 19.50 10.90 63.19% 9.22 47.28% 12.89 66.1% Changjiang County 23.20 25.45 10.51 45.30% 12.08 47.47% 10.56 41.5%

1 Resident population means population resident in an area (more than half a year).

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2.2 Economic Situation Although Hainan has undergone drastic changes in economic and social development, its backwardness has not been altered radically: According to the 2018 Statistical Yearbook of Hainan Province, Hainan’s per capita GDP in 2017 was US$7,179, ranking 17th in China of total 34 provincial areas, while its GDP was 446.254 billion yuan, ranking fourth from the last in China; In 2017, Hainan’s per capita disposable income of residents was 22,553 yuan, per capita disposable income of urban residents 30,817 yuan, and per capita disposable income of rural residents 12,902 yuan, lower than the national averages of 25,974 yuan, 36,396 yuan and 13,432 yuan respectively.

The key industries of Hainan are tourism, tropical characteristic efficient agriculture, Internet, healthcare, finance and insurance, conference and exhibition, etc. In 2017, the ratio of primary, secondary and tertiary industries was 22%, 22.3%, 55.7% respectively, in which the contribution of service industries to economic growth was as high as 79.5%. Hainan receives 67.45 million men-times of tourists annually, and its annual tourism income is 81.2 billion yuan.

2.3 Health and Medical Care Hainan’s average healthy life expectancy is 76.0 years (67.8 years), lower than the national average 76.2 years (68.0 years), its death rate of pregnant and lying-in women is higher than the national average, while its death rate of children below 5 years, infants and newborns is lower than the national average. Almost all children are covered by vaccination.

According to 2019 Issue 3 of the Death Cause Monitoring Brief of Hainan Province, the primary death cause of Hainan is malignant tumor, followed by heart disease, cerebrovascular diseases, respiratory diseases, and injury and poisoning, where the top 5 death causes for males are malignant tumor, heart disease, cerebrovascular diseases, respiratory diseases, and injury and poisoning, and those for women heart disease, cerebrovascular diseases, malignant tumor, respiratory diseases, and injury and poisoning, similar to the national situation. The major categories of diseases are infectious maternal and child diseases, nutritional deficiency diseases, injuries, and chronic non-communicable diseases (chronic diseases for short), where chronic diseases have the highest contribution among all death cases (82.26%).

Since Hainan is a tropical island in southern China, with a tropical monsoon climate, rich rainfall, and distinct dry and rainy seasons, local common diseases include rheumatism, gout, arthritis, cervical and lumbar pain, etc., and the incidences of rheumatism and cataract are higher among rural women than men.

The Hainan health system is medium ranking in China. In 2017, Hainan had 5,177 PHC providers, including 25 centers for disease control, 24 maternity and child care centers, 15 specialized disease prevention and treatment institutions, 175 community health service institutions, and 299 township health centers, with 42,000 sickbeds and 60,600 health workers in total, including 20,900 medical practitioners (assistants), 28,500 registered nurses and 3,000 pharmacists. However, only 33.7% of doctors and assistant doctors, and 25.9% of registered nurses work at PHC providers. There are only 1.22 general practitioners (GPs) per 10,000 people, just 2/3 of the national average, and only 4.53 sickbeds per 1,000 people, also below the national average (5.72).

6 3 Stakeholder Needs 3.1 Stakeholder Identification According to the Feasibility Study Report, the Project consists of the following aspects: ①TA research and innovation; ②IT building; and ③human resources building. The primary stakeholders of the Project are: 1) Rural and urban residents, and migrant population, including 9.2576 million local rural and urban residents, and a migrant population of 1.31 million; 2) Vulnerable groups, including 4.4 million women, 70,000 poor residents and 165,742 minority residents in 27 cities, counties and districts in Hainan Province; 3) 9,724 (in 2017) PHC practitioners (rural and family doctors) in Hainan Province; 4) PHC providers: 5,177 PHC providers in Hainan Province, including 25 centers for disease control, 24 maternity and child care centers, 15 specialized disease prevention and treatment institutions, 175 community health service institutions, 299 township health centers, 51 community health centers, and 1,312 village clinics; 5) Hainan Provincial Health Commission (HPHC, including information center) and Hainan Healthcare Security Administration (HHSA, Hainan PMO) 6) Medical alliances, mainly including county / city top three hospitals, such as Hainan General Hospital, Hainan Nongken General Hospital, Affiliated Hospital of Hainan Medical University, and central hospitals

See Table 3-1. Table 3-1 Primary Stakeholders Attitude to Direct stakeholder Rights and duties remarks the Project HPHC (including information center) and Project coordination, regulation and Positive HHSA implementation management Hainan Provincial Development and Research Project assessment and approval Supporting Reform Commission tasks Hainan Provincial Finance Department Financial management Supporting Information Protecting and managing the systems WFs Supporting interests of women Institutional Protecting and managing the capacity EACs Supporting interests of minority residents building Protecting and managing the PAOs Supporting interests of Poor People Design agency Project design and research Positive Research PHC providers (township health centers Project implementation Positive tasks / community health centers and clinics) Information Providing advanced medical systems Medical alliances technologies and staff for two-way Positive Institutional diagnosis and treatment capacity Improving their own medical level, PHC practitioners Positive building and increasing training opportunities Enjoying better medical services at Rural residents Positive the village level Community Enjoying better medical services at Local residents Positive Research residents the community level tasks Enjoying better medical services in Migrant population Positive Information their locations systems Enjoying better medical assistance Vulnerable groups Women for gynecological diseases at the Positive primary level

7 Enjoying such medical services as Poor People healthy diagnosis and treatment, and Positive a green channel Enjoying medical treatment that is Minority residents Positive identical to or better than Han people

3.2 Stakeholder Attitudes and Needs According to the fieldwork in Baoting Li-Miao Autonomous County, Wuzhishan City, Sanya City and Haikou City, including in-depth interviews with PHC works, urban and rural residents, and migrant population, all stakeholders highly support the Project, and think that it will be beneficial to the public and has no negative impact. See Table 3-2.

Table 3-2 Analysis of Stakeholder Attitudes and Needs Stakeholder Data source (venue and interviewee) Attitude and needs PHC • Baoting County: head of the Xiangshui  Supporting the Project and thinking that it is provider Town Health Center; rural doctors in very necessary workers Hekou Village;  Improving PHC service level as expected by • Wuzhishan City: head of Hainan No.2 all Hainan people, and not excluding poor People’s Hospital; head of the Maoyang people Town Health Center; rural doctors of  Increasing salaries of rural doctors Maojian Village Clinic  Improving capacity through training • Sanya City: head of the Fenghuang  Establishing incentives for primary doctors Community Health Center; workers of  Establishing and improving a feedback the Sanyawan Community Health Center channel for medical service evaluation • Haikou City: head of the Haiken results Community Health Center; head and workers of the Binya Community Health Center Urban and • Baoting County: villagers in Hekou  Supporting the Project and thinking that it is rural Village; villagers visiting the Xiangshui very necessary residents Town Health Center  Improving PHC service level • Wuzhishan City: residents visiting  Enjoying high-quality medical services Hainan No.2 People’s Hospital nearby • Sanya City: residents visiting the  Improving medical care level Fenghuang and Sanyawan Community  Participating in the Project to receive more Health Centers information • Haikou City: patients of the Haiken  Offering more publicity and workshops on Community Health Center; urban health knowledge residents, etc. Migrant • Wuzhishan City: migrant population  Supporting the Project and thinking that it is population visiting Hainan No.2 People’s Hospital very necessary • Sanya City: migrant population in  Improving medical care level Fenghuang and Sanyawan  Establishing a hierarchical medical service Communities; system to meet diverse needs • Haikou City: migrant population in  Improving medical care level for Longhua District cardiovascular diseases  No negative impact

Poor • Baoting County: poor people in Hekou  Supporting the Project and thinking that it is population Village, Xiangshui Town very necessary • Wuzhishan City: poor people  Improving PHC service level  Enjoying high-quality medical services nearby  Establishing a long-term support mechanism for poor people  Offering more publicity and workshops on health knowledge

8  No negative impact

Minority • Baoting County: Li, Miao and Hui  Supporting the Project and thinking that it is residents residents very necessary • Wuzhishan City: Li and Miao residents  Improving PHC service level  Enjoying high-quality medical services nearby  Offering more publicity and workshops on health knowledge  Providing language support to some people, especially old people for convenient medical care

Women • Baoting County: women and minority  Supporting the Project and thinking that it is women in Hekou Village very necessary • Wuzhishan City: rural women and  Improving PHC service level minority women; women visiting Hainan  Enjoying high-quality medical services No.2 People’s Hospital nearby • Sanya City: women in Fenghuang and  Offering more publicity and workshops on Sanyawan Communities health knowledge • Haikou City: women in Longhua District  Participating in the Project to receive more and Binya Community information  Improving the infrastructure and service level of PHC providers, such as nurseries and child activity rooms, for convenient medical care

3.3 Social Benefits of the Project Before project implementation, some local residents tend to receive medical care at county level or above hospitals for some common chronic diseases, resulting in expensive and difficult medical care. The Project aims to improve the medical service level of primary hospitals, and increase the utilization rate of PHC, thereby benefiting 5.56 million rural residents in the province, especially 70,000 poor rural residents. After project completion, public health resources will be allocated more evenly between urban and rural areas, enabling rural residents, especially poor rural residents, to receive medical care more conveniently, and increasing the utilization rate of PHC providers. The building of IT systems, medical alliances and rural doctor teams will improve the operating efficiency of PHC providers, reduce personal medical financial burden, and alleviate poverty due to diseases.

In 2017, the outpatient expense per man-time at general hospitals in Hainan Province was 263.6 yuan, and the inpatient expense per man-time was 10,603.7 yuan. Township health centers often cannot treat major diseases due to the shortage of medical staff and equipment, while county hospitals are usually crowded. Rural residents need to pay travel expenses and accommodation fees due to the long distance, so it is expensive and hard to see a doctor in county hospital, especially for poor rural residents. At FGDs, all stakeholders highly support the Project, and consider it will bring benefits to the public and has no negative impact.

9 4 Project Impacts on Poor People 4.1 Poor People of Hainan Province According to the Three-year Action Plan for Poverty Alleviation of Hainan Province issued by the Hainan Provincial Government in September 2018, there are 33,000 poor households with 122,600 persons, 83 poor villages (including 35 deeply poor villages), and 5 poor counties (cities) in Hainan, with a poverty incidence of 2.2%.

At the end of 2018, Hainan’s poor population dropped to 70,000, and the per capita disposable income of rural residents in poor areas was 11,545 yuan, a year-on-year increase of 1,233 yuan. This increase is attributed to the implementation of new rural cooperative medical care, critical illness insurance, medical assistance, social assistance and minimum living security for poor people in recent years, and the increase of the pension rate increases to 178 yuan/month by 22.8%.

Baoting County was no longer a poor county in 2019 and has a poverty incidence of 0.27%. The poverty incidence of Wuzhishan City dropped from 28.2% in 2016 to 1.3% at the end of 2018, and it aims to turn the city into a non-poor city by the end of 2019.

4.2 Medical Services of Poor People Healthcare Services Providing to Poor People The national public healthcare services are fundamental services offering to all residents for free, with focus on children, pregnant and lying-in women, old people and chronic disease patients. All residents in Hainan are entitled to the national public healthcare services provided by centers for disease control, community health centers, township health centers, and other urban and rural PHC agencies, and are public welfare intervention measures. Compared to non-poor people, poor people prefer such services. Currently, 14 national public healthcare services2 are available for free at the expense of the government. In 2019, the per capita fiscal subsidy for public healthcare services of Hainan is 55 yuan.

The overall proportion of population impoverished by diseases in Hainan is 7.13%. Since July 2017, the Three-year Action Plan for Poverty Alleviation of Hainan Province was implemented, which includes 5 major actions, namely basic medical insurance for poor people, capacity building of PHC providers, targeted treatment of major and chronic diseases, integrated prevention and control of key infectious diseases and local diseases in poor areas, and mother and child healthcare in poor areas, to support poor people. See Table 4-1.

2 Namely health file management of urban and rural residents, health education, preventive inoculation, health management of children aged 0-6 years, health management of pregnant and lying-in women, health management of old people, health management of chronic disease patients (hypertension, diabetes), serious psycho management, health management of TB patients, reporting and handling of infectious diseases and public health emergencies, TCM health management, health and family planning supervision, free supply of contraceptives, and health literacy promotion

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Table 4-1 Summary of Health Poverty Alleviation in Hainan Province Covered Covered Covered Percentage of Covered populati population population population Administrative division poor on lifted impoverished impoverished impoverished population out of due to not due to due to diseases poverty diseases diseases Hainan Province 527876 401617 88615 37644 7.13% Haikou City 11613 10753 492 368 3.17% Sanya City 6023 5706 146 171 2.84% Danzhou City 53502 33030 13880 6592 12.32% Wuzhishan City 18991 16002 1962 1027 5.41% Qionghai City 13179 11918 906 355 2.69% Wenchang City 16486 14596 1042 848 5.14% Wanning City 37822 24527 8304 4991 13.20% Dongfang City 44893 27252 13246 4395 9.79% Ding’an County 29896 19345 7202 3349 11.20% Tunchang County 27424 21705 4631 1088 3.97% Chengmai County 18653 14623 2898 1132 6.07% Lingao County 53373 47424 4196 1753 3.28% Baisha Li Autonomous County 39185 33108 4700 1377 3.51% Changjiang Li Autonomous 20738 18096 1564 1078 5.20% County Ledong Li Autonomous County 53915 37684 12107 4124 7.65% Lingshui Li Autonomous 36018 29439 4411 2168 6.02% County Baoting Li-Miao Autonomous 23207 18225 3349 1633 7.04% County Qiongzhong Li-Miao 21532 17288 3305 939 4.36% Autonomous County Yangpu Economic 1426 896 274 256 17.95% Development Zone Source: HPHC; as of December 31, 2018

According to the Three-year Action Plan for Poverty Alleviation of Hainan Province, HPHC has included all poor people in basic medical insurance for urban and rural residents, commercial supplementary insurance for major diseases and medical assistance. The part of payment made by individual of poor people to the basic medical insurance for urban and rural residents has been fully subsidized by public finance. Under new rural cooperative medical care, critical illness insurance, commercial supplementary insurance for major diseases, civil affairs medical assistance, and special fund for medical security, the actual percentage of reimbursement of hospitalization expenses is over 90%, and that of outpatient expenses for 25 chronic diseases is over 80% for poor people. 100% of medical expenses of extremely poor people are reimbursed. The full coverage of basic medical insurance, critical illness insurance and supplementary insurance for major diseases for registered poor households in Hainan has been largely realized.3

In addition, local poor people have access to a priority channel offered by all public medical institutions, where they can receive medical care before payment, be hospitalized without paying a deposit, and enjoy one-stop settlement services. This measure can simplify the medical care procedure, and provide truly affordable, effective and convenient medical care to them. A health poverty alleviation management database has been established in Hainan, and there are health

3 Source: Hainan Daily, August 19, 2019, Hainan: Critical illness insurance relieves medical care pressure

11 poverty alleviation wards at general hospital of level II in Wuzhishan City.

Figure 4-1 Green Channel for Medical Care of Poor Patients

Family doctors are contracted to cover key groups with priority, including old people, special families in family planning, poor rural residents, pregnant and lying-in women, children, disabled people, and patients of chronic diseases (hypertension, diabetes, TB, etc.) and serious mental disorder. In 2019, the full coverage of the registered poor rural residents has been realized. In addition, medical alliances4 provide convenient medical care to rural residents, especially poor rural residents, improve the quality and efficiency of medical care at PHC providers, and enable rural residents to treat basic diseases at primary hospitals, thereby saving medical expenses.

Healthcare Practice of Poor People According to a study on medical care choices of rural residents (Huang Xiaoling, Zhang Fan, et al., 2016), rural residents suffering from chronic diseases are more inclined to receive medical care at county level or above hospitals than those not suffering from chronic diseases (about 1.61 times), rural residents closer to the nearest medical institution (3km or less) are more inclined to receive medical care at PHC providers than those farther away from the nearest medical institution (more than 3km). In addition, rural residents aged 60 years or above are more inclined to receive medical care at PHC providers than those aged 18-40 years and 41-60 years, and those with higher educational levels (senior high school or above) are more inclined to receive medical care at county level or above hospitals than those with lower educational levels (junior high school or below).5 It can be seen that medical care choices of rural residents are affected mainly by state of illness, distance, age, educational level, income level, etc. According to the field survey, rural residents visiting village clinics are mostly old people aged 60 years or above, who have limited mobility or can hardly operate means of transport, and often go to village clinics for acute cold and other minor diseases, or routine checks of chronic diseases (e.g., hypertension), young rural residents prefer township health centers, and sick infants are sent directly to county hospitals or top three hospitals.

Poor people, especially rural poor people, are more inclined to use PHC. Statistics show that among 1/5 of the poorest rural population of Hainan, 78.2% receive primary medical services, and

4 The medical alliances are reginal healthcare unit groups. It integrates the healthcare resource together in the dedicated regions, by including Top 3 hospitals, Top 2 hospitals, community hospitals and village healthcare centers in general. It aims to address the problem in difficult doctor seeing and try to avoid crowding to the Top 3 hospitals for just minor problems such as cold and fever that could be treated in primary healthcare centers. 5 Huang Xiaoling, Zhang Fan, et al., 2016, Medical Care Choices of Rural Residents in Hainan Province and Influencing Factors, Chinese Health Service Management, Issue 3.

12 69.6% chose hospitalization at medical institutions in the county, with an average expense of 15,489 yuan per stay, with a self-spending rate of 42.2%. The fieldwork also finds that poor people prefer PHC providers. In addition, poor people spend much money and time on healthcare, even more than non-poor people, because they would see a doctor when diseases develop to a certain extent and prefer doctors who prescribe drastic drugs to try to recover soon.

It can be seen that a whole set of systems and measures for the disease prevention and treatment, and daily healthcare of poor people has been established in Hainan, and these measures have taken effect. On the other side, poor people, especially rural poor people, are more inclined to use PHC. Due to various reasons, the utilization of PHC is not sufficient.

4.3 Project Impacts on Poor People By implementation of the project, poor people that use PHC more frequently will benefit directly from the improved medical service level of primary hospitals. With the upgrading of PHC resources and the expansion of medical capacity after project completion, they will continue to enjoy health poverty alleviation policies and preferences. For example, local people have access to a priority channel at the primary level, over 90% of their medical expenses can be reimbursed, and all registered poor rural residents have contracted with family doctors, and the full coverage of basic medical insurance, critical illness insurance and supplementary insurance for major diseases for registered poor households has been largely realized. The Project will reduce medical care costs of ordinary residents (including traffic and time costs) who prefer county and provincial hospitals to PHC providers greatly. Therefore, the Project will have no negative impact on poor people.

However, in order to improve the sustainability of the Project, a long-term health security mechanism should be established for poor people to avoid impoverishment due to diseases. In addition, in order to consider poor people in project design and implementation, and enable them to share the project benefits equally, a SEP has been developed, implemented, adjusted and improved during the implementation according to the particular situation and needs.

Finally, health education and promotion for poor people should be strengthened, such as giving routine publicity and education on chronic diseases for poor people to improve their self-protection and medical care awareness, organizing health experts and workers to hold health workshops in poor villages, and setting up fitness facilities and health bulletin boards in poor villages.

13 5 Project Impacts on Migrant Population 5.1 Current Situation of Migrant Population Hainan attracts a large migrant population from other provinces during winter season due to its tropical climate. From October 1, 2017 to April 30, 2018, the migrant population in Hainan was as large as 1.65 million, in which retirees aged 60 years or above accounted for 56%, in which 40% are retirees of public institutions, 34% retirees of government agencies and troops, and 26% retirees of enterprises. The migrant population is mostly from northern China, and about 1/4 is from Beijing, Inner Mongolia, Hebei and Shandong.6 The migrant population and the number of visitor’s trends to be increasing in Hainan. It is expected that the resident migrant population and the average number of night-stay visitors per day will be 640,000 and 170,000 in 2020, and 930,000 and 260,000 in 2030 respectively.7

In addition, according to the 2018 Statistical Yearbook of Hainan Province, at the end of 2017, Hainan had a resident migrant population of 514,100 and a floating migrant population of 795,700, totaling 1.3098 million.

5.2 Health and Medical Care of Migrant Population The warm climate and low relative humidity of Hainan can alleviate rheumatism, rheumatoid arthritis, pulmonary emphysema, tracheitis, cardiovascular and cerebrovascular diseases common in old people significantly. The main diseases among the migrant population are sudden respiratory diseases, and non-sudden cardiovascular and cerebrovascular diseases. Over 90% of the migrant population seeking medical care is retirees from different cities, who recuperate in Hainan from October to February. The migrant population is mostly distributed in such cities as Sanya and Haikou. The proportion of the migrant population in Wuzhishan does not exceed 1/3 of the local population in winter.

The migrant population in Hainan is divided into two types in general: 1) Resident migrants (living in Hainan for over 6 months without changing household registration) mostly live in communities and have similar medical care habits as local residents. They go to community health centers for the treatment of ordinary diseases, and the routine diagnosis and medication of chronic diseases (hypertension, diabetes, etc.), and go to top three hospitals for major diseases or chronic diseases with acute complications (coronary heart disease, kidney disease, etc.). 2) Floating migrants (living in Hainan for not more than 6 months, mostly in winter) prefer Top three hospitals, because they are unfamiliar with the local medical environment. Retirees suffering from chronic diseases like cardiovascular and cerebrovascular diseases are the main part of the migrant population, and choose Top three hospitals when they come to Hainan for medical care and recuperation. Visitors often choose Top three hospitals for urgent conditions. Therefore, the utilization rate of PHC among floating migrant population and visitors is low. A comprehensive analysis shows that the proportion of migrants going to township health centers is very low, and their outpatient visits account for about 3% of all outpatient visits.

All residents of Hainan, whether urban or rural, registered or not, are entitled to national PHC services, so the resident migrant population is also entitled. In order to meet the needs of

6 http://dy.163.com/v2/article/detail/E7IP2LDG0524D3HJ.html 7 Source: 2018 Statistical Yearbook of Hainan Province

14 healthcare services of the migrant population, Hainan has been taking efforts in addressing medical settlement needs from 2009. As of September 2016, the scope of non-local medical settlement cooperation of Hainan had been expanded to 30 provinces (regions, municipalities) of China. In addition, a non-local medical care database for migrants has been established and is updated in real time.

In addition, the survey shows that migrants, especially resident migrants, have been included in local medical plans from 2009. A practical measure to deal with the medical care pressure brought by floating migrants in winter is providing additional staffs to the dedicated PHC areas temporarily during the periods under the overall management of reginal or provincial healthcare level, by which the PHCs can address the working pressure during those busy periods on the one hand, and do not need to afford for such a group of additional staffs in the non-busy periods on the other hands. Therefore, it is usually acceptable for PHC providers, mostly community health centers to ensure normal operation. After project completion, migrants will equally benefit from the Project without occupying local residents’ medical resources.

5.3 Project Impacts on Migrant Population The Project will promote health tourism, recuperation and healthcare, and the balanced and sustainable development of Hainan’s economy, especially the health industry. In addition, the reform under the Project will improve Hainan’s PHC resource capacity, quality and efficiency, and enable migrants to receive more convenient and better medical services locally.

Hainan has realized nationwide non-local medical settlement cooperation and established a non-local medical care database for migrants, so that migrants can receive medical care and apply for expense reimbursement in Hainan. On the other side, the medical care pressure brought by floating migrants in winter is usually acceptable for PHC providers as mentioned, mostly community health centers, which can be staffed temporarily to ensure normal operation. In addition, the project proposes to further improve the capacities in providing healthcare services to Hainan local people as well as migrants. For example, strengthening Hainan Healthcare Information Technology System will be able to integrate the information of the patients in the whole Hainan healthcare system, which will improve the efficiency for medical treatment of migrants who may be moving around the province day-by-day; in parallel, the healthcare agencies’, especially PHCs’, pressure will be further relieved. The similar outcome like the component of IT system strengthening will be also generated on other areas, for example, the strengthening of medical alliances.

As above, after the project completion, migrants will benefit from the Project without occupying local residents’ medical resources.

15 6 Project Impacts on Women 6.1 Women’s Health Status In 2017, Hainan had a resident population of 9.2576 million, in which males accounted for 47.6%. According to the Analysis of Results of Women’s Reproductive Health Screening of Hainan Province, the common gynecological diseases of women aged 20-64 years are cervicitis, hysteromyoma, bacterial vaginosis, candidal vaginitis, largely consistent with those of nationwide women.8 According to official statistics, by the end of 2017, the premarital medical examination rate of women in Hainan was 38.7% (urban: 36.81%; rural: 41.59%), the hospitalized delivery rate was 99.93% (rural: 99.91%), and the antenatal examination rate was 96.40%. In 2018, 300,000 women were screened for common diseases, 90,000 women for cervical cancer, and 40,000 women for breast cancer, and the regular screening rate of common diseases of women was 70%.

A survey on reproductive health status on married rural women of childbearing age in Hainan and influencing factors by Hainan Medical University shows that the awareness of reproductive health knowledge among married rural women of childbearing age is 48.5%, and the holding rate of reproductive health behaviors is 61.6%; the key factors affecting awareness are occupation, satisfaction with own health, and self-reported personal attention to health.9 Therefore, it is very necessary to improve contractual services of family doctors, and regulate and improve the management of women’s health education services.

6.2 Use of Primary Healthcare by Women A survey on medical service use among 1,182 rural women in Hainan by Hainan Medical University shows that 24.1% of rural women do not receive medical care when they ought to, and 34.8% do not receive medical care timely when they ought to, and the key factors preventing them from receiving medical care are financial difficulty, inconvenience and busy work. Factors affecting outpatient service use mainly include ethnic group, annual household income, insurance period, diagnosis waiting time, health status, chronic disease or not, etc.; factors affecting inpatient service use mainly include annual household income, insurance period, distance from the nearest medical institution, health status, chronic disease or not, etc. The outpatient visiting rate of rural minority women is higher than that of rural Han women, possibly because further support is available in minority areas in recent years.

The outpatient visiting and hospitalization rates of rural women with poor health and suffering from chronic diseases are high, indicating that the medical care problem of rural women has been alleviated and their health service demand simulated to some extent since new rural cooperative medical care was implemented. The longer the insurance period is, the higher the outpatient visiting and hospitalization rates will be, because rural women with a longer insurance period are more aware of the policies of new rural cooperative medical care, such as reimbursement percentage, drugs covered and reimbursement procedure, and benefit more from these policies, thereby reducing their medical financial burden.10

8 Huang Cuimin, Kong Lingwan, Dou Qianru, et al, 2019, Analysis of Results of Women’s Reproductive Health Screening of Hainan Province, China Tropical Medicine, Issue 1. 9 Yang Zaijia, Zhu Juan, Miu Feiyan et al, 2017, Study on Reproductive Health Status on Married Rural Women of Childbearing Age in Hainan Province and Influencing Factors, Chinese Journal of Public Health Management, Issue 4. 10 Huang Xiaoling, Wu Ling, Zhang Fan, 2014, Analysis of the Current Situation of Utilization of Medical Services by Rural Women in Hainan Province and Influencing Factors, Maternal and Child Health Care of China, Issue 30.

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6.3 Women’s Health Program The Women’s Development Plan of Hainan Province (2011-2020) (2012) proposes the following measures for the health development of local women: 1) strengthening support for women’s development in rural, poor and minority areas to reduce urban-rural gaps in healthcare services; 2) continuing to expand the coverage of medical insurance for urban workers, urban residents basic medical insurance and new rural cooperative medical insurance to provide institutional support to urban flexibly employed and unemployed women, and rural women; 3) providing premium subsidies for new rural cooperative medical care and basic medical insurance for urban residents to disabled women; 4) eliminating the discrimination against girls; 5) improving the maternal and child health system, and expanding the coverage of reimbursement under medical insurance for frequently encountered diseases of women, and strengthening knowledge and skills training for maternal and child health staff, and family planning service providers; and 6) strengthening the maternity department building and staff training of PHC providers to improve the healthcare level of pregnant and lying-in women. By 2020, the antenatal examination rate of pregnant and lying-in women will be over 90%, their systematic management rate over 85%, and their hospitalized delivery rate over 98% (over 96% for rural pregnant and lying-in women).

6.4 Project Impacts on Women As part of Hainan’s overall efforts on women healthcare development, the Project will contribute to this target from improvement of PHC healthcare service. After the completion of the Project, the capacity of PHC providers to provide public health services to women and children will be further improved, such as replenishing folic acid for pregnant women, and conducting free cervical and breast cancer screening for women, and free screening of gynecological diseases for women aged 20-64 years, thereby ensuring that women receive necessary health services and maintain physical health. In addition, a new round of standardization has been completed for maternal and child care centers.

On this basis, the Project will further improve PHC conditions, level and capacity for women, improve contractual services of family doctors, regulate and improve the management of women’s health education services, and increase the awareness of reproductive health knowledge and premarital examination, thereby improving the health level of women, especially rural women.

Over 50% of workers and over 90% of nurses of PHC providers (township and community health centers, etc.) are women, but only a small number of county hospitals and community health centers have a nursery or child activity room. As a suggestion to the FSR design, the PHC providers should set up nurseries to meet the breastfeeding need of female workers. In addition, the capacity building of female workers should be strengthened to increase their career development opportunities.

The key factors preventing rural women from receiving medical care are financial difficulty, inconvenient transportation and busy work such as housework, cooking, caring for the elderly and children. Another suggestion for FSR is that township health centers should set up a child activity room for the convenience of women and children to receive health care.

Also, health publicity and education for women should be included in the project design. WFs

17 should play a role in organizing health experts and workers to give publicity on the protection of female occupational and gynecological diseases, cervical and breast cancer screening, pregnancy examination, antenatal examination, etc. to improve the health level and awareness of women, especially rural women.

18 7 Project Impacts on Minority Population 7.1 Minority Population According to the 2018 Statistical Yearbook of Hainan Province, at the end of 2017, Hainan had a minority population of 1,657,423, accounting for 18.2% of gross population, including 1,502,415 Li people (15%), 79,515 Miao people, 40,218 Zhuang people, 13,225 Hui people, and 22,050 people of other ethnic minorities, distributed mainly in Sanya and Wuzhishan Cities, and Baoting, Qiongzhong, Lingshui, Baisha and Changjiang Counties. Among the 4 sample cities / counties, the percentages of minority population of Wuzhishan City, Baoting County, Sanya City and Haikou City are 73.3%, 69.5%, 42.7% and 2% respectively.

There are over 30 ethnic minorities in Hainan, in which Han, Li, Miao and Hui are resident ethnic groups, while other ethnic groups have moved in after 1949 and are scattered. The Li, Miao and Hui people mostly live in central and southern Hainan, while the Han people mostly in northeast and north of Hainan, and coastal areas.

The dialects spoken in Hainan include: 1) Hainan dialect, which is the dialect most spoken in Hainan by over 5 million residents; 2) Li language, which is spoken by all Li people; 3) Lingao dialect, which is close to the Zhuang language and is spoken by about 500,000 residents; and 4) Miao language, which is spoken by about 50,000 Miao people. In the 4 sample cities / counties, almost all minority residents can speak the Hainan dialect or Mandarin, except some old people aged above 75 years or those leading a secluded life in mountains.

Table 7-1 Populations and Features of Main Ethnic Minorities in Hainan Province Ethnic Population Distribution Language Religion minority (0,000) Living centrally in Lingshui, Baoting, Li language (no written Animism, totemism, Sanya, Ledong, Dongfang, language) ancestral worship Changjiang, Baisha, Qiongzhong and and natural worship Wuzhishan Cities / Counties, and Li 150.24 scattered in Wanning, Danzhou, Tunchang and Qionghai Cities / Counties mainly

Located mainly in central and Miao language (no Ancestral worship southern mountain areas, and around written language), no and natural worship Miao 7.95 Li settlements, dealing with farming dialectic difference and cultivation mianly

Scattered in Hainan Province Zhuang language (no Taoism, Mo religion, written language), high ancestral worship Zhuang 4.02 popularity of Mandarin and natural worship

Living mainly in Huihui and Huixin Hui language (similar Islam Villages, Niulan Town, Sanya City, to Arabic) mostly Persians and Arabs, with Hui 1.32 some being Hui descendants from Mainland China

Source: 2018 Statistical Yearbook of Hainan Province; as of December 31, 2018

19 7.2 Health and Medical Care of Minority Population Minority residents are similar to Han residents in health status and diseases. In Wuzhishan City, Li and Miao residents have a higher incidence of thalassemia for genetic reasons, and patients are mostly from poor families with a weak sense of antenatal examination. In addition, some minority residents especially men, are more likely to drink alcohol and chew betel nut, so that they have a higher incidence of liver cirrhosis and oral mucosal disease than Han male residents.

In terms of medical treatment procedures and payment, the use of primary medical care by ethnic minorities is no different from that of the Han nationality. In addition, although some minority residents can’t speak the Hainan dialect or Mandarin, there are many doctors and nurses speaking the Li language in rural primary healthcare teams, so their medical care is not affected.

The minorities of Hainan are mostly inhabiting in the center and mountain areas of the province where PHCs serves fundamental services of people’s healthcare. Since the utilization of PHC is not sufficient, Hainan government has been taking efforts for improving the healthcare services of minorities.

7.3 Minority Health Program The Hainan Provincial Government has promulgated a series of policies on public service system building in minority areas. The 13th Five-year Plan for Minority Work of Hainan Province proposes to improve the public health service system in minority areas at the county / city, township / sub-district and village / community levels, facilities of medical institutions, and rural health services, with focus on rural healthcare facilities, thereby meeting basic medical needs of minority residents.

Flexible ways are explored actively in minority areas to attract and retain more medical workers, including increasing their salaries and subsidies. The PHC service pattern, and the hierarchical diagnosis and treatment system are improved to improve health conditions in minority areas, especially remote mountain areas. In addition, new rural cooperative medical care and medical insurance for urban residents will be integrated into a uniform medical insurance for urban and rural residents in minority areas.

The critical illness insurance system for urban and rural residents will be implemented comprehensively, and the security mechanism for critical diseases further improved, so that county hospitals in minority areas largely meet the national standard on service capacity of county hospitals. By 2020, a 30-minute PHC service circle will be largely established, and there will be 6 sickbeds, two medical practitioners (assistants) and 2.7 registered nurses per 1,000 residents.

7.4 Project Impacts on Minority Population The Project is part of efforts of Hainan Provincial Government for improving the healthcare services of minorities. In general, minority residents in Hainan have no difference from Han people in terms of health status, medical care preferences and procedure, medical policy, health poverty alleviation policies, etc. With the implementation of the Project, minority residents will benefit from more medical resources, and higher primary healthcare quality and efficiency, especially poor minority residents.

Although some minority residents cannot speak the Hainan dialect or Mandarin, there are many

20 doctors and nurses speaking the Li language in rural primary healthcare teams, so their medical care is not affected. However, as suggested, language help desks should be set up at PHC providers to assist minority residents.

In order that minority residents fully participate in and equally benefit from the Project, a participatory framework should be established for minority residents.

21 8 Conclusions and Suggestions 8.1 Conclusions 8.1.1 The Project is beneficial to all stakeholders and does not exclude vulnerable groups. Currently, Hainan’s PHC includes national PHC services, basic medical insurance for urban residents and new rural cooperative medical care, and covers urban residents, rural residents and migrants. The primary stakeholders of the Project are: 1) Rural and urban residents, and migrant population, including 9.2576 million local rural and urban residents, and a migrant population of 1.31 million; 2) vulnerable groups (including 4.4 million women, 70,000 poor residents and 165,742 minority residents in 27 cities, counties and districts in Hainan Province); 3) 9,724 (in 2017) PHC providers practitioners (rural and family doctors) in Hainan Province; 4) PHC providers, namely township health center, community health centers and village clinics; 5) HPHC and HHSA; and， 6) medical alliances, mainly including county / city top three hospitals, such as Hainan General Hospital, Hainan Nongken General Hospital, Affiliated Hospital of Hainan Medical University, and central hospitals.

For all urban and rural residents using PHC: 1) After project completion, Hainan’s healthcare conditions will improve greatly, especially in rural areas, thereby reducing the death rates of children below 5 years, infants, pregnant and lying-in women, and patients of major and chronic diseases, thereby increasing the average healthy life expectancy; 2) A high-quality, value-based medical service system will be established, and PHC capacity and efficiency improved. 3) After project completion, public health resources will be allocated more evenly between urban and rural areas, enabling rural residents, especially poor rural residents, to receive medical care more conveniently, and increasing the utilization rate of PHC providers. The building of IT systems, medical alliances and rural doctor teams will provide inexpensive, nearby and easy medical services to rural residents.

All stakeholders highly support the Project and think that it will be beneficial to the public and has no negative impact.

 Poor population At the end of 2017, Hainan had 33,000 poor households with 122,600 persons. They rely more on PHC, and will benefit directly from the improved PHC service level.

Currently, poor residents in Hainan have access to a priority channel, the percentage of reimbursement of medical expenses is over 90%, and the full coverage of basic medical insurance, critical illness insurance and supplementary insurance for major diseases for registered poor households has been largely realized.

With the upgrading of PHC resources and the expansion of medical capacity after project completion, medical care costs of ordinary residents (including traffic and time costs) who prefer county and provincial hospitals to PHC providers will be reduced greatly. The building of IT systems, medical alliances and rural doctor teams will improve the operating efficiency of PHC providers, reduce personal medical financial burden, and alleviate poverty due to diseases.

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After project completion, poor people will continue to enjoy health poverty alleviation policies and preferences.

 Ethnic minorities The minority population is distributed mainly in Wuzhishan City, Baoting, Qiongzhong, Lingshui, Baisha, Ledong and Changjiang Counties. Minority residents in Hainan have no difference from Han people in terms of health status, medical care preferences and procedure, medical policy, health poverty alleviation policies, etc.

Although some minority residents cannot speak the Hainan dialect or Mandarin, there are many doctors and nurses speaking the Li language in rural primary healthcare teams, so their medical care is not affected.

With the implementation of the Project, minority residents will benefit from more medical resources, and higher quality and efficiency of primary healthcare, especially poor minority residents. Minority areas will pay more attention to cultivating minority medical personnel and enhance the ability of ethnic minorities to participate in and utilize primary health care services.

 Women In Hainan, free cervical and breast cancer screening, and free screening of gynecological diseases are available to women aged 20-64 years, and a new round of standardization has been completed for maternal and child care centers.

The Project will further improve PHC conditions, quality and capacity for women, improve contractual services of family doctors, regulate and improve the management of women’s health education services, and increase the awareness of reproductive health knowledge and premarital examination, thereby improving the health level of women, especially rural women.

The outpatient visiting rate of rural minority women is higher than that of rural Han women. The outpatient visit rate and hospitalization rate of rural women with poor health and chronic diseases are higher, indicating that rural women’s medical treatment has been alleviated since the implementation of the new rural cooperative medical system. After project completion, continued support for poor rural women will solve their medical care difficulties.

8.1.2 Migrant population will not occupy local residents’ medical resources. Based on field investigations and literature review, the utilization rates of medical resources of village clinics, township and community health centers in Hainan range from 30% to 80% meaning that the higher-level medical resource has a higher level utilization rate. Medical resources are generally sufficient for medical care demand.

At the end of 2017, Hainan had a resident migrant population of 514,100 and a floating migrant population of 795,700, totally 1.3098 million. The main diseases among the migrant population are sudden respiratory diseases, and non-sudden cardiovascular and cerebrovascular diseases. Over 90% of the migrant population seeking medical care is retirees from different cities in China, who recuperate in Hainan from October to February annually.

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Resident migrants (living in Hainan for over 6 months without changing household registration) mostly live in communities and have similar medical care habits as local residents. They go to community health centers for the treatment of ordinary diseases, and the routine diagnosis and medication of chronic diseases (hypertension, diabetes, etc.), and go to Top three hospitals for major diseases or chronic diseases with acute complications (coronary heart disease, kidney disease, etc.).

Floating migrants (living in Hainan for not more than 6 months, mostly in winter) prefer Top three hospitals, because they are unfamiliar with the local medical environment. Visitors often choose Top three hospitals for urgent conditions. Therefore, the utilization rate of PHC among floating migrant population and visitors is low.

In order to meet the needs of healthcare services of the migrant population, Hainan has been taking efforts in addressing medical settlement needs from 2009. As of September 2016, the scope of non-local medical settlement cooperation of Hainan had been expanded to 30 provinces (regions, municipalities) of China. In addition, a non-local medical care database for migrants has been established and is updated regularly. A practical measure to deal with the medical care pressure brought by floating migrants in winter is providing additional staffs to the dedicated PHC areas temporarily during the periods under the overall management of reginal or provincial healthcare level, by which the PHCs can address the working pressure during those busy periods on the one hand, and do not need to afford for such a group of additional staffs in the non-busy periods on the other hands. Therefore, it is usually acceptable for PHC providers, mostly community health centers to ensure normal operation.

In addition, the project proposes to further improve the capacities in providing healthcare services to Hainan local people as well as migrants. For example, strengthening Hainan Healthcare Information Technology System as well as medical alliances. Those will improve the efficiency for medical treatment of migrants who may be moving around the province day-by-day; in parallel, the healthcare agencies’, especially PHCs’ pressure will be further relieved.

In conclusion, migrants have been considered in local medical/health development plans and will benefit from the Project without occupying local residents’ medical resources after project completion.

8.2 Suggestions The Project is a public service project. The investment in the Project will be focused on technical design, service transformation, and primary healthcare improvement. The Project will involve no construction, no land acquisition, and no materially adverse impact on local communities and minorities. In order to solicit comments from broadly stakeholders and equally benefit all groups of people, especially for poor people, the following suggestions are proposed:

 Poor people: Establish an effective participation mechanism and a long-term support mechanism. 1) According to the prevailing policy, registered poor households are entitled to health poverty alleviation policies and preferences. The Three-year Action Plan for Poverty Alleviation of Hainan

24 Province proposes to further strengthen poverty alleviation from 2019. In order to improve the sustainability of the Project, a long-term support mechanism for poor people should be established. 2) In addition, in order to consider poor people in project design and implementation, and enable them to share the project benefits equally, the SEP has been developed, implemented, adjusted and improved during the implementation according to the particular situation and needs.

 Ethnic minorities: Establish a mechanism for minority residents to participate effectively in PHC building in a suitable manner. 1) Attention should be paid to health worker training in minority areas. Statistics show that the number of health workers per 10,000 people in minority areas is much lower than the urban level and the provincial average, indicating that rural residents are disadvantaged in public health services. Therefore, it is necessary to improve the public health service system in minority areas at the county / city, township / sub-district and village / community levels, facilities of medical institutions, and rural health services, with focus on rural healthcare facilities, thereby meeting basic medical needs of minority residents. 2) Although some minority residents cannot speak the Hainan dialect or Mandarin, there are many doctors and nurses speaking the Li language in rural primary healthcare teams, so their medical care is not affected. However, language help desks should be set up at PHC providers to assist minority residents. 3) In order to ensure minority residents fully participate in and equally benefit from the Project, a engagement framework has been established for ethnic minority people.

 Women: Strengthen the capacity building of female workers and set up nurseries and child activity rooms. 1) Over 50% of workers and over 90% of nurses of PHC providers (township and community health centers, etc.) are women, but only a small number of county hospitals and community health centers have a nursery or child activity room. PHC providers should set up nurseries to meet the breastfeeding need of female workers. In addition, the capacity building of female workers should be strengthened to increase their career development opportunities. 2) Research shows that 24.1% of rural women do not receive medical care when they ought to, and 34.8% do not receive medical care timely when they ought to. The key factors preventing rural women from receiving medical care are financial difficulty, inconvenience and busy work, including housework, cooking, caring for the elderly and children. Township health centers should set up a child activity room for the convenience of women and children.

 Pay attention to demand differences in health education and publicity. The survey shows that there are differences in health status and demand between residents in poor and non-poor areas, minority and Han residents, men and women, and local residents and migrants, different measures should be developed in health knowledge publicity, disease screening and control, medical treatment, and medical security policy under the Project. 1) Poor population: Poor people, especially rural poor people, are more inclined to use PHC. In addition, poor people spend much money and time on healthcare, even more than non-poor people, because they would see a doctor when diseases develop to a certain extent. Therefore, health

25 experts and workers should be organized to hold health workshops to advocate a healthy and civilized lifestyle, and fitness facilities and health bulletin boards set up in poor villages to improve the constitution and health awareness of poor people. Since poor people have high incidences of cardiovascular and cerebrovascular diseases, diabetes, and other chronic non-communicable diseases, health education and promotion for poor people should be strengthened, such as giving routine publicity and education on chronic diseases for poor people to improve their self-protection and medical care awareness. 2) Ethnic minorities: Compared to Han people, minority residents have some special diseases. For example, Li and Miao residents have a higher incidence of thalassemia for genetic reasons, and patients are mostly from poor families with a weak sense of antenatal examination. In addition, some minority residents, especially male minority residents, like drinking and chewing betel nut, so they have higher incidences of liver cirrhosis and oral mucosa diseases. In addition, some minority residents are superstitious in medical care. Health publicity for minority residents should be conducted in a culturally appropriate manner, and a healthy lifestyle advocated. Language barriers should also be considered during healthy publicity. 3) Gender differences: Men and women have differences in health status and health service demand. For example, rural women have higher incidences of rheumatism and cataract; women are more in need of the prevention and treatment of gynecological and breast diseases, and gynecological examination, while men are more in need of the prevention and treatment of bronchus, colon, liver and prostate diseases. Therefore, health knowledge publicity, and disease screening and prevention programs should be developed pertinently based on such differences. In health knowledge publicity for women, consideration should be given to their availability, because they have to take care of children and do housework. Besides, WFs should play a role in organizing health experts and workers to give publicity on the protection of female occupational and gynecological diseases, cervical and breast cancer screening, pregnancy examination, antenatal examination, etc. to improve the health level and awareness of women, especially rural women.

26 Appendix 1 Statistics of Workforce of Township Health Centers in Hainan Province and Sample Cities / Counties

Health workers Medical Assistant Western Personnel Administrative Work TCM Examination Imaging Interns practitioners practitioners Registered medicine quota division force N Midwives medical medical medical Other nurses medical N TCM N TCM assistants assistants assistants N TCM In Out assistants Hainan 4869 3249 723 47 541 26 1156 88 217 78 51 232 163 13 3334 1378 Province Baoting Li-Miao Autonomous 418 81 18 1 22 3 28 4 6 1 2 102 29 County Haikou City 2061 515 132 12 68 3 201 10 38 17 5 33 11 2 476 295 Wuzhishan City 225 61 13 3 14 16 1 3 1 2 11 56 28 As of July 5, 2018 TCM = traditional Chinese medicine

Appendix 2 Summary of Stakeholder FGDs

City / Date No. Participants Venue Key points county 1 HC office 1. Project introduction (PHC, minority population, women and poverty Xiangshui Town Health alleviation in Baoting County) 2 Baoting County HC, PAO, EAC and Center 2. Public consultation: use of PHC, awareness of and needs for the Project, Sep. Baoting WF; head of the Xiangshui Town 3 Hekou Village Clinic potential impacts of the Project, suggestions on the Project, etc. 18th County Health Center; rural doctors and 3. Organizational consultation: composition, staffing, functions, capacity villagers of Hekoku Village 4 Hekou villagers’ families building; role in project design and implementation; cooperation; needs for the Project, potential impacts of the Project, suggestions on the Project, etc. 5 Wuzhishan Municipal HC, PAO Wuzhishan Municipal HC 1. Project introduction (PHC, minority population and poverty alleviation in and EAC; contact of Hainan No.2 Hainan No.2 People’s Wuzhishan City) 6 People’s Hospital; villagers of Hospital 2. Public consultation: use of PHC, awareness of and needs for the Project, Sep. Wuzhishan 7 Maogui Village; head of the Maogui Village Comittee potential impacts of the Project, suggestions on the Project, etc. 19th City Maoyang Town Health Center; Maoyang Town Health 3. Organizational consultation: composition, staffing, functions, capacity 8 rural doctors of the Maojian Village Center building; role in project design and implementation; cooperation; needs for 9 Clinic Maojian Village Clinic the Project, potential impacts of the Project, suggestions on the Project, etc. Sep. 10 Sanya City Sanya Municipal HC, EAC, PAO Sanya Municipal HC 1. Project introduction (PHC, minority population, women and poverty 27

20th and WF; head of the Fenghuang Fenghuang Community alleviation in) 11 Community Health Center; staff of Health Center 2. Public consultation: use of PHC, awareness of and needs for the Project, the Sanyawan Community Health potential impacts of the Project, suggestions on the Project, etc. Center Sanyawan Community 3. Organizational consultation: composition, staffing, functions, capacity 12 Health Center building; role in project design and implementation; cooperation; needs for the Project, potential impacts of the Project, suggestions on the Project, etc. Longhua DistrictHaiken 1. Project introduction (PHC, minority population, women and poverty 13 Longhua DistrictHC; Haikou Community Health Center alleviation in Haikou City) CityLonghua Districthead of the Binya Community Health 2. Public consultation: use of PHC, awareness of and needs for the Project, Sep. 14 Haikou Haiken Community Health Center; Center potential impacts of the Project, suggestions on the Project, etc. 21st City head and staff of the Binya 3. Organizational consultation: composition, staffing, functions, capacity 15 Community Health Center Office of HPHC building; role in project design and implementation; cooperation; needs for the Project, potential impacts of the Project, suggestions on the Project, etc.

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Appendix 3 Flowchart of Priority Medical Care for Registered Poor Patients

Registered poor patient

Guided medical care Management by medical dept.

Disease evaluation

Outpatient diagnosis Inpatient diagnosis

Preparing a treatment Patient admission based on medical scheme insurance card Improving health file

Admission to relevant department Diagnosis and treatment

Treatment

Applying for government assistance

Discharge Discharge

29 Appendix 4 Fieldwork Photos

September 18: interview with rural doctors at September 18: interview with the head of Xiangshui the Hekou Village Clinic, Xiangshui Town, Town Health Center in Baoting County Baoting County

September 18: interview with minority residents and September 18: interview with an old minority women in Hekou Village, Xiangshui Town, Baoting resident in Hekou Village Clinic, Xiangshui County Town, Baoting County

September 18: poster and brochure of health September 19: interview with an old minority poverty alleviation policy in Baoting County resident at Wuzhishan No.2 People’s Hospital

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September 19: family doctor service September 19: health poverty alleviation ward of management chart of the Maoyang Town Health Wuzhishan No.2 People’s Hospital Center in Wuzhishan City

September 19: medical alliance consultation September 19: bulletin board of health poverty flowchart at the Maoyang Town Health Center in alleviation policy in Maoyang Town, Wuzhishan Wuzhishan City City

September 19: contractual serivces of rural September 19: interview with rural doctors in doctors in Maozhan Village, Maoyang Town, Maozhan Village, Maoyang Town, Wuzhishan City Wuzhishan City

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September 20: medical insurance policy for poor September 20: green channel for poor people in rural residents in Sanya City Tianya District, Sanya City

September 20: interview with the head of the September 20: interview with local residents and Fenghuang Community Health Center in Tianya migrants in in Tianya District, Sanya City District, Sanya City

September 21: doctor team and PHC services September 21: interview with the head of the of the Haiken Community Health Center in Haiken Community Health Center, Haikou City Haikou City

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September 21: introduction to diagnosis and September 21: interview with the head of the Binya treatment experts of the Binya Community Community Health Center in Haikou City Health Center in Haikou City

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