Effects of anti-corruption campaigns on cesarean section rate: evidence from China

The excessive use of Cesarean sections (CS) globally is a serious concern, exceeding the World Health Organization's (WHO) recommended rate of 10-15%. In China, the rate reached 47.8% in urban areas in 2018, leading to various adverse short-term and long-term effects for mothers and infants. One contributing factor is physician incentives; CS procedures often generate higher revenue than vaginal births, creating financial incentives for unnecessary procedures. This behavior can be viewed as a form of corruption, defined as the misuse of entrusted power for personal gain. In China, reduced government funding for public hospitals since the 1980s forced them to become self-financing, pushing physicians towards profit-seeking behaviors, such as unnecessary surgeries and accepting bribes. CS procedures, with their higher profit margins, became a key source of revenue for obstetrics departments. The Xi Jinping administration's anti-corruption campaign, starting in late 2012, provides a unique opportunity to study the effect of changing social norms on medical practices. This study examines whether this campaign, although not explicitly targeting the health sector, indirectly reduced unnecessary CS rates by impacting the social environment of corruption and influencing physician behavior in Shanxi Province, a region notorious for its high levels of corruption.

Existing research highlights the global problem of excessive CS rates and the role of physician incentives in driving this trend. Studies show how financial incentives, malpractice concerns, and convenience can influence physician decision-making towards CS, even when medically unnecessary. Previous research has examined interventions to reduce unnecessary CS, including educational programs, mandatory second opinions, and audits, but with mixed success. In China, the high CS rate has been linked to the financial structure of public hospitals and the resulting incentives for physicians. While numerous studies have explored the effects of China's anti-corruption campaign on various economic and social outcomes, few have investigated its impact on the healthcare sector. This study addresses this research gap by examining whether the campaign's influence on the social environment surrounding corruption can indirectly reduce unnecessary CS rates by changing physician behavior.

This study uses a combination of three datasets: the China Corruption Investigation (CCI) Dataset (corruption investigations), the China Stock Market and Accounting Research (CSMAR) Database (firm-level data), and hospital discharge records from 137 public hospitals in Shanxi Province. The CCI dataset provided information on the intensity of anti-corruption campaigns in Shanxi, measured by the number of officials investigated. The CSMAR dataset allowed the researchers to calculate the ratio of firms' business entertainment spending to revenue as an indicator of local corruption levels. Hospital discharge records provided patient-level data on delivery methods, diagnoses, and other relevant characteristics. A two-stage least squares (2SLS) instrumental variable (IV) approach was used. The first stage regressed the city-level corruption (business entertainment spending ratio) on the intensity of anti-corruption campaigns in the previous year. The second stage regressed CS rates on the predicted corruption level, controlling for patient characteristics, city-level factors, and year fixed effects. The study also explored heterogeneous effects by insurance status, number of births, and physician level (head of department, attending physician, resident physician). Robustness checks included using the change in corruption levels as the regressor and examining the impact on stent use in acute myocardial infarction cases.

The study found a significant negative correlation between anti-corruption campaign intensity and CS rates. A one standard deviation decrease in the local corruption level was associated with a 3.3% reduction in the overall CS rate. This effect was more pronounced among patients admitted through outpatient schedules (3.5% reduction) and was not significant for emergency admissions. Heterogeneous effects were observed. The reduction in CS rates was larger among insured patients (almost double the main effect) and those with second or later deliveries (almost six times the main effect). Analyses at the physician level revealed significant reductions in CS rates among attending and resident physicians, primarily driven by outpatient admissions. Robustness checks using the change in corruption level yielded similar results. Additional analyses on stent use in AMI treatment showed a reduction in both stent surgery rates and the number of stents used, suggesting a broader impact of the anti-corruption campaign on physician behavior.

The findings suggest that China's anti-corruption campaign, even without direct targeting of the healthcare sector, significantly reduced unnecessary CS rates by changing the social environment and influencing physician behavior. The observed reductions were primarily driven by a decrease in unnecessary procedures, particularly among less price-sensitive patients (insured and those with subsequent births) and among junior physicians. The study supports the notion that interventions aimed at modifying social norms surrounding corruption can have significant, positive impacts on healthcare practices. The results highlight the potential of broad-based anti-corruption initiatives to indirectly improve healthcare quality and reduce unnecessary medical procedures.

This study provides novel empirical evidence demonstrating the effectiveness of anti-corruption campaigns in reducing unnecessary CS rates. The findings suggest that tackling corruption, even indirectly, can improve healthcare practices. The effect was strongest among specific patient groups (insured and those with later births) and physician types (attending and resident physicians), indicating the campaign's influence on both patient choices and physician behavior. Future research should explore the long-term effects of such campaigns, examine the generalizability to other settings, and investigate other potential mechanisms through which anti-corruption initiatives affect healthcare.

The study's analysis focuses on the short-term effects of the anti-corruption campaign in Shanxi Province, limiting the generalizability of the findings. Data availability restricted the analysis to a specific region and time period, potentially hindering broader interpretations. While the study used instrumental variables to address potential endogeneity, other unobserved factors might still influence CS rates. The specific mechanisms through which the campaign influenced physician behavior require further investigation.