Evaluation of China's health system from the perspective of TB underreporting

Abstract

Background: As the country with the third largest TB epidemic, China has a major responsibility to control the prevalence of TB. A standardized health information system is required to monitor the TB epidemic and the performance of the national TB control program. However, the capacity of the health information systems to detect infectious diseases in China need further enhancement. It is widely perceived that the problems of underreporting exist in China’s infectious diseases reporting systems, but little is known about the extent of underreporting as no rigorous empirical research has been conducted. Therefore, the aim of this study is to empirically analyze the issues of TB underreporting, identify weaknesses in the health information systems, and make suggestions for improvement.

Methods: This study utilized a mixed method approach to evaluate China’s health information system by identifying the problems of TB underreporting in Zhenjiang, China. Using the data of 2,136 TB cases from the hospital information and TB information management systems, we analyzed the extent to which TB cases are underreported through chi-square test and multivariable logit regression. We subsequently conducted policy document review and evaluated the transcripts from 19 interviews to investigate the key factors causing TB underreporting.

Results: Our study indicates that approximately 29.3% of TB cases in Zhenjiang city are unreported. The unreported rates of outpatients are higher than the unreported rates of inpatients except the cases in Jurong Hospital. Generally, inpatients who did not reside in their jurisdiction had higher unreported rates than those inpatients living in their jurisdiction for a long period. Moreover, patients without a personal ID card had higher unreported rates than those with ID cards. Additionally, underreporting among inpatient was significantly higher than non-in-hospital referrals.

Through in-depth interviews, we discovered the potential factors causing TB underreporting are poor system design and some human resource related issues. More specifically, for the former one, hospitals use different electronic systems to record patient information, which often causes confusion when TB reporters search the records for a TB diagnosis. The lack of a self-check function reduces the accuracy of data reported. Moreover, the health information systems lack interoperability among different health facilities, which slows the transfer of information and creates room for mistakes. For the latter one, clinicians and hospital statisticians reflected that the heavy workload and low financial incentives made them reluctant to report TB cases timely and accurately. What’s more, the absence of specific and unified standards for health workers from different cities, counties, and facilities with which to comply is also evident. The limited requirements of government intensified the chaos generated during the establishment of information systems at the local level. The political context of inadequate incentive policies and low degree of supervision aggravated the quality of implementation.

Conclusion: We found that the lack of self-check function, lack of data standardization, lack of system interoperability and accessibility, heavy workload for healthcare workers, lack of awareness of reporting, lack of financial incentives, absence of surveillance, and lack of guidance and role clarity are associated with TB underreporting. Our study reveals the important role of system design, government leadership, and qualified, dedicated, and well- paid health personnel play in ensuring the accuracy of data.