| BackgroundIn the "Alma-Ata Declaration", the World Health Organization proposed the establishment of primary health care system to achieve the grand blueprint of "Health for All by 2000", in September 1978. Unfortunately, the global strategic objective was not accomplished on schedule. With the rapid global growth in health cost, health inequality has become increasingly prominent. As a developing country, China is also facing the same dilemma. Medical services and medical technology have greatly improved since the adoption of reform and opening-up policy in China, but the issues of difficult and expensive to get medical service are also increasingly prominent. Health developments and reforms face many deep-rooted contradictions and problems.New health care reform policy was promulgated on April 6,2009. One of the highlights was the main objectives to establish universal coverage of public health service system, medical service system, medical security system and medicine supply system and proposed to solve the problem of difficult and expensive to get medical service. The US Congress passed the health care reform bill submitted by the Obama government on March 25,2010. It was not an accidental coincidence that two large countries announced health care reform in succession and it precisely reflected the importance and urgency of contemporary health system reform. As one important part of a public welfare system, health care system has concentrated many social contradictions and it has become the worldwide difficult issue in social economic system reform. China and U.S. had issued the decree on health care reform, and it seemed that they were trying to solve the social contradictions. If we wanted to break the bottleneck of health care reform, we must solve the problem that was difficult and expensive for people with low-income and beyond policy coverage to access to get medical service. This problem could trace its roots to rational allocation and utilization of health resources. As the basis for the sustainable development of health, health resource allocation was directly related to the people's health benefits and fairness. It was one of the crucial issues that must be solved to sustain the health development. Health resources were strongly scarce and limited in various countries. Therefore, how to allocate health resources rationally and equitably to meet the needs of all residents has become a primary problem. Under this condition, undoubtedly, study on health resources allocation and health services must have outstanding theoretical and practical value.Objective1 Find out health resources allocation in Guangdong Province; provide the basic data for setting a balanced structure and appropriate scale of health resources allocation.2 Evaluate the efficiency and equity of the health resources allocation in Guangdong Province; probe into measures to keep the health resources allocation both equitable and efficient; provide the theoretical basis for promoting the overall optimization of health resources in Guangdong Province.3 Reveal the status of the health services in Guangdong Province at present; provide the basis for effectively regulating the relationship between supply and demand on health services; provide basic information for formulation and implementation of health care reform policy in the future.4 Present some policy suggestions for the sustainable development of health resources allocation, utilization mechanisms and systems to relevant government departments.Methods1 Collect data from Statistical Yearbook of Guangdong Province, Health Statistics Yearbook of Guangdong Province, Ministry of Health Web site, Guangdong Statistical Information Network, Guangdong Provincial Health Department Website and Medical and health information network in Guangdong over the years to describe the status and trends of health resources allocation in Guangdong Province and evaluate the efficiency of health resources allocation.2 Evaluate the equity of health resources in Guangdong Province with application of Lorenz curve, Gini coefficient and Theil Index.3 Survey the needs, demands and utilization status of health services in urban and rural residents in Guangdong Province by using multi-stage stratified cluster random sampling method.Results1. Health Material Resources Allocation1.1 The total number of health institutions increased significantly from 15,500 in 2002 to 16,238 in 2009, with 9,890 (68.9%) in the Pearl River Delta and 6,348 (39.1%) in non-pearl River Delta. State-owned health institutions continued to hold the leading position, accounting for 43.5%. The proportion of private health sectors had increased to 37.9%.1.2 The total number of hospitals and health centers had increased by 51 in recent 5 years. Pearl River Delta and the non-pearl River Delta had different proportions of secondary and tertiary hospitals of the province (56.5% and 68.3% for Pearl River Delta respectively) 1.3 The total number of ward beds in medical institutions was 272,000 and continued to increase. Inpatient service capacity had been enhanced. The number of ward beds varied significantly in different regions in Guangdong province. The Pearl River Delta had 167,317(61.5%) and non-Pearl River Delta had 104,655(38.5%).1.4 The coverage of village health centers increased year by year; the community health services had developed and expanded rapidly; 28,070 village health centers had been set up and covered 89.8% villages; 1,984 community health services centers had been established with 3,629 beds.1.5 The number of the equipments whose value was more than ten thousand yuan continued to increase steadily.256,158 sets of large equipments were in Guangdong province with the total value of 35.98 billion yuan. Viewed from the agency distribution, hospitals had a maximum of equipments, followed by the health centers, maternity and child care, disease prevention and control centers, community health centers, clinics, blood collection and supply agencies. Viewed from the distribution of urban and rural, the number of equipment and the total value accounted for 92.37% and 95.63% respectively in city. In the other hand, rural areas only accounted for 7.63% and 4.37% respectively.2. Health Human Resources Allocation2.1 The total number of health technical workers had been increasing year by year. But it was neither balanced in regional distribution, nor rational in educational background and qualifications structure. According to the results of the survey, there were 413 thousand health technical workers in Guangdong Province and 4.94 health technical workers per thousand people (Registered Permanent Residence).277,977 of them (67.2%) were in Pear River Delta, and 135,467 of them (32.8%) were in non-Pearl River region. Among these health technical workers, people with college diploma accounted for 69.6%, while people with bachelor degree or above accounted less than 25%. People without titles or with primary titles accounted the vast majority, while people with middle titles accounted low.2.2 There were 156 thousand medical practitioners (assistants) in Guangdong Province,1.62 medical practitioners (assistants) per thousand people, which was below the national average.66.4% of them distributed in the Pearl River Delta and 33.6% in the non-Pearl River Delta. Medical practitioners (assistants) with low-educated owned a high proportion and 52% of them had a college diploma or below. The age structure was more reasonable, with adults aged between 25 and 54 accounted 87.7%.2.3 There were 151 thousand Registered Nurses in Guangdong Province,1.81 registered nurses per thousand people (the Registered Permanent Residence) which was higher than the national average (1.39/1000 people).107,241 of them (70.9%) were employed in the River Delta.2.4 The number of rural doctors and health workers was small and the overall quality was low. There were 34 thousand rural doctors and health workers in Guangdong Province, and 0.78 doctors and health workers per thousand rural people (the Registered Permanent Residence), which was below the national average. Rural doctors and health workers with college diploma accounted for 7.4%; secondary educations accounted for 43.6%; secondary level accounted for 21.6%; training qualified accounted for 27.4%.3 Health Fund Allocation3.1 The total health expenses were 112.54 billion yuan in Guangdong Province in 2008, accounted for 3.15% of GDP. And average per capita health expenditure was 1,182.4 yuan. Over the same period, the total health expenses were 1453.54 billion yuan in China in 2008, accounted for 4.83% of GDP. And average per capita health expenditure was 1,094.5 yuan. During 2003-2008, the total health expenditures had increased from 57.71 billion yuan to 112.54 billion yuan, with the annual growth rate of 15.84%. The average per capita health expenditure had increased from 725.6 yuan to 1182.4 yuan, with the annual growth rate of 10.50%.3.2 Government expenditure was in low proportion among the composition of the total cost, but it showed an increasing trend year by year. The proportion of social expenditure had increased steadily year by year. Personal spending accounted for a higher proportion of total health expenditure, but gradually declined in recent years.3.3 Health system obtained financial investment of 11.297 billion yuan(accounted for 2.62% of financial expenditure) in Guangdong Province in 2009.Over the same period, national health expenditure was 118.056 billion yuan(accounted for 2.7% of financial expenditure) in China in 2009. Among the financial investment of 11.297 billion yuan in Guangdong Province,4.412 billion yuan was for municipal hospital,2.032 billion yuan for Center for Disease Control and Prevention,1.742 billion yuan for township hospitals,0.852 billion yuan for Community Health Center,0.679 billion yuan for county hospitals,0.475 billion yuan for health inspection agencies,0.288 billion yuan for maternity and child care centers,0.201 billion yuan for blood banks and 0.616 billion yuan for other institutions.4 Macro-efficiency of Health Allocation4.1 The Situation of Infectious Disease ControlThe incidence of A and B infectious diseases was 244.23/100 thousand people, and the mortality rate was 1.13/100 thousand people during the investigation in Guangdong Province. While, the incidence of A and B infectious diseases was 263.52/100 thousand people, and the mortality rate was 1.12/100 thousand people during corresponding time period in China. Incidence of diseases among the top five were tuberculosis, syphilis, hepatitis B, gonorrhea and hepatitis C in Guangdong Province, which accounted for 86.81% of total incidence. Over the same period, incidence of diseases among the top five were virus hepatitis, tuberculosis, syphilis, dysentery and Influenza H1N1 flu, which accounted for 91.5% of total incidence.4.2 Maternal and Child Health CareThe rate of antenatal examination for pregnant women was 94.8%,90.4% for postpartum visits, and 96.7% for hospital delivery in Guangdong Province. Over the same period, the rate of antenatal examination for pregnant women was 94.8%, 90.4% for postpartum visits, and 96.7% for hospital delivery in China. Maternal mortality rate was 13.9/100 thousand pregnant women and infant mortality rate was 4.4%o during the investigation in Guangdong Province While over the same period, maternal mortality rate was 31.9/100 thousand pregnant women, and infant mortality rate was 13.8‰in China.4.3 The Average Life Expectancy of the ResidentsThe average life expectancy of the residents in Guangdong province was 75.3 years, which was 2.3 years higher than the national average and 0.81 years higher compared with 2002. Health status of urban and rural residents had been close to the level of moderately developed countries.5 Health Resources Allocation and Utilization Ratio 5.1 Residents in Guangdong Province tended to have their inpatient and outpatient treatments, hospitalized observation and health check-ups in hospitals, health centers and MCH. Community health service centers, clinic, nursing stations and other basic rural medical institutions were in low utilization ratio.5.2 The overall operating is efficient in Guangdong Province. Daily clinic visits, daily burden of the bed-days and occupancy rate of beds at all levels of medical institutions were above the national average. And the average length of stay was below the national average. Efficiency of primary health care sectors needed to be improved. Residents'average daily hospital bed-days burden, beds utilization and hospital beds days in primary health centers were far below than in the medical institutions at high level, such as hospital and MCH.5.3 Technical efficiency of health resources allocation was not significantly improved. Inpatient therapeutic index showed no significant improvements in cure rate and mortality. The proportion of health care expenses in the whole consumption increased year after year; the average treatment and hospitalization costs showed a significant rising trend with years; the average hospitalization costs were 1.28 times higher than the national average. Drug expenditure took a large part of the hospital income and loss of medical expenses was made up by a surplus of drags and other incomes. Large equipments were frequently used with a low positive test rate, which indicated a suspicion of induced-demand.6 Evaluations on the Fairness of Health Resources Allocation6.1 The Health Resources Allocation in the Lorenz curve and Gini CoefficientFrom 2004 to 2009, Gini coefficient of health institutions allocation was 0.227, 0.232,0.249,0.261,0.277 and 0.269 respectively; Gini coefficient of ward beds allocation in hospitals and health centers was 0.214,0.220,0.228,0.217,0.21 land 0.209 respectively; Gini coefficient of registered medical practitioner allocation was 0.215,0.219,0.228,0.233,0.242 and 0.250 respectively. And all of them were in the best fair condition. Changes in overall Theil index and Gini coefficient showed the same trend.6.2 Health Resources Allocation in Theil Index From 2004 to 2009, Theil index of health institutions allocatio was 0.0402, 0.0407,0.0466,0.0512,0.0638 and 0.0615 respectively.; Theil index of the ward beds allocation in hospitals and health centers was 0.0331,0.0351,0.0350,0.0337, 0.0324 and 0.0310 respectively; Theil index of registered medical practitioner allocation was 0.0321,0.0334,0.0350,0.0361,0.0393 and 0.0408 respectively.The results, decomposed from the overall Theil index, showed no obvious variation in the inside interval gap of the health institutions allocation. The interval gap continued to widen and it fastened the disparities within Guangdong Province. The unbalanced degree of health institutions allocation was growing between Pear River Delta and non-Pear River Delta. The unbalanced of the beds allocation was reflected by the large regional internal differences in Pear River Delta and non-Pear River Delta. The unbalance of the registered medical practitioners'allocation was showed by the large gap between two regions.7 Health and Health Service Needs of Surveyed Population7.1 Two-week prevalence of surveyed population was 32.3%, which was much higher than the national average (18.9%). Moreover, these indexes of the severity degree of diseases, such as two-week sick days, two-week sick days in bed, two-week absent days due to illness, were slightly higher than the national average. The top five diseases for two-week prevalence were circulatory system, respiratory system, movement system, and endocrine system and digestive system diseases. The top five types of diseases were the same compared with the national survey data, with order partly changed. Prevalence of chronic diseases was roughly equaled to the national survey data, but the top five categories showed significant different with national survey data.7.2 There were obviously differences between urban and rural demographic characteristics. The aging of the urban population was higher than rural areas, while the population under 14 years old in rural areas was larger than urban. Secondly, there were obvious differences between rural areas and urban in two-week prevalence, type of two-week sick illness, severity and the spectrum of chronic disease.8 Requirements and Utilization of Health Resources of Surveyed Population 8.1 The demands of outpatient services were higher than the national average, with rural higher than urban and female higher than male.8.2 Only 25.6% of the urban residents had treatments in clinics and community health stations-the primary health care institutions.74.4% of the urban residents chose country or higher hospitals for treatment and 79% of them preferred the hospitals at or above city. In contrast,78.2% of rural residents had treatments in clinics and community health stations-the primary health care institutions. Only 21.8% of the rural residents chose country or higher hospitals for treatment and 81.3% of them chose the hospitals at country level as their first preference when they required hospitalization. Geographic accessibility and economic factors were the main reasons that affected residents on choosing medical treatments places.8.3 The visit rate within two weeks of the investigated people was 24.8%(rural 26.2%, urban 23.1%), which was higher than the national average. The non-visit rate within two weeks was 28%, which was lower than the national average. Hospitalization rate was 6.2% and required hospitalization but without hospitalization rate wasl4.7%(rural 18.3%, urban 8.3%) which was lower than the national average. The length of admission days and operation ration of discharged patients was equal to the national average. But the length of admission days for urban residents was longer than rural.8.4 The expenditure was 145.4 yuan for outpatient per time of surveyed people, which was lower than the national average.7516.5 yuan for hospitalization per time and it was higher than the national average (5058 yuan).8134.4 yuan for hospitalization of urban residents per time and it was lower than national average (8958).7085.5 yuan for hospitalization of rural residents and it was higher than the national average (3685).9 Satisfaction Degree with Health system among ResidentsThe proportion of dissatisfaction with outpatient services accounted for 45.9% in urban and 27.3% in rural. The proportion of dissatisfaction with hospitalization accounted for 45% in urban and 35.5% in rural. The reasons for dissatisfaction with out-patients were as followings:long waiting time (42.5%), bad service attitudes (24.8%), complicated process (13.3%), high costs (8.7%), poor equipment environment (3.1%) in urban. And in rural the reasons respectively were high costs (27.3%), bad service attitudes (18.8%), unreasonable charges (15.2%), and complicated process (13.7%) and long waiting time (8.5%). The leading reasons for dissatisfaction with hospitalization were high costs (25%), long waiting time (7.5%) and bad service attitudes (6.5%) in urban. And in rural were high costs (28%), complicated process (9.7%) and poor environment (6.5%) respectively.Conclusions1. Allocation of total medical material resources keeps a steady growth. While layout and structural imbalances also exist, manifested in the following ways. High level medical institutions and high-grade equipments mainly concentrate in the Pearl River Delta and large cities.2. Total health human resources are consistent with the growth of economy. But the overall quality of staffs is not high and regional disparities exist in the distributions of human health resources.3. Total health expenditure shows a continuous growth, and the proportion of government spending is too low in the financial structure which leads to a heavy burden on individuals.4. The efficiency of health resources allocation is improving; a Pareto improvement space exists in allocation; technical efficiency shows a decreasing trend generally.5. The high efficiency of medical services coexists with inadequate utilization of health resources; the adverse selection of primary health care institutions exacerbates the low efficiency of resource use.6. The current allocation of health resources in Guangdong Province remains in fair condition. But it does not mean that all residents can enjoy the same medical and health service quality across the province, because differences of the health resources allocation remain in the Pearl River Delta and the non-Pearl River Delta.7. Residents' requirements for health service in Guangdong Province are more than the national average; disease spectrums are quite different with the results of national statistics; significant differences between urban and rural residents exist in health service requirements.8. The utilization and demands for health service in Guangdong Province remain in a high level and they will continue to grow, together with the social and economic development.9. The high cost of health service for urban and rural residents in Guangdong Province hinders the utilization of health service. It manifests specifically in that health expenditure takes a large proportion in the total consumption and hospitalization costs are high; People who are required hospitalization but without hospitalization and non-visit in two-week sick are due to economic reasons.10. It is urgent to improve health services quality. "The issue of difficult and expensive to get medical service" for urban and rural residents is still the main problem. The degree of satisfaction with the health system needs to be improved.Policy Recommendations1 The development of overall medical resources should be adapted to social-economic developments to keep the balance of supply and demands for medical resources.2 The government should play a leading and supervisory role for health resources allocation, and gradually change the distribution of medical resources allocation in regions, urban and rural areas.3 Promote the reform of public medical institutions; encourage and guide the social capital to develop medical and health services.4 Adjust the structure of medical resources at present; support the development of primary health services system; make up for the growth in demand for health resources and structural imbalances.5 Improve health service qualities. Pay a close attention to the health of floating population.6 Health resource allocations in Guangdong province should adhere to a fair and efficient developing model.7 Market researches about health services should be carried out regularly to adjust health resource allocation; to improve the efficiency and equitability.8 Strengthen the supervision of government and industry; upgrade the health services quality and behaviors... |
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