Study On Operational Mechanism And Systems Building Of Community Health Service In China

BACKGROUDFrom the 60's in the 20th century, more and more attention has been paid to the organization and the function implementation of Community Health Service (CHS). Especially for present century, it is the inevitable trend to develop CHS and find an appropriate management mode to deal with such problems as the people ageing, fee-for-service keeping rising, non-infectious chronic disease increasing, and so on. Today,many countries have conducted CHS throughout the world.The role of CHS is to guarantee people the rights of primary medical and public health service so as to improve health, prompt and keep social equity and stabilization. CHS can improve rational and effective allocation of resources, and also can make the medical units to shift and find their right orientation in health service system.In 1997, the government of China made it clear in The Decision On Reform And Development Of Health Care that we should change the urban health service system and develop community health service so as to form a service network which is reasonable and convenient to people. From then on, the CHS has developed quickly. After ten years, the urban community health service network was established. The organization types are different and the holders of the units are diversity.Nowdays, it is generally identified with the idea that the CHS is the trend of health care development. But the economy level among different areas is so different that the development of CHS is unbalanced and facing many problems.The present problems as follows: a)many CHS units didn't have their clear service mission and the target population edging, b) the current management system weakened the commonweal character of the CHS units, c) the conception and the service mode of the CHS were lagged behind, d) the modern management regulations and systems were missing that the CHS efficiency was not high. All these problems severely restricted the development of the CHS. It is crucial to reform the present management mode and to probe for the appropriate mechanism that suit for the modern times' development.In these years, there are some studies on CHS. However these researches mainly focused on such aspects as "should be", that is the political policy, basic status analysis, basic function and items, human resource, and so on. But studies on "how to do" which means the organization types and the service mode construction were relatively less. And most were local, some are merely review and summarization. It is scarce of the study on the mechanism and management mode as a whole and systemically one.We implemented this investigation with the aid of relevant projects carried out by the Urban Health and Poverty Project (UHPP), and were the bran-item of the ministry of Science and Technology and the Ministry of Health of the PRC. We explored to construct an appropriate management system and regulations that fit with the development of modern time's economy and the changes of health demands. And in this research we used such theory as system design, management and organization and whatever, to develop a new system which can ensure the CHS to exert its function. So it can meet the health demands changes of people, standardize the behavior of the medical units and the GPs, and provide sustainable and practical guiding on theory.METHODOLOGYLiterature review was used to study the mechanism and management mode of CHS abroad and the development of domestic CHS. Combined with the survey and the data collected in 10 national CHS demonstrate-districts, we design the CHS management system with adapted regulations based on such materials as the theory of organization and management, theory of management, system theory and cybernetics logistics system and dilevery chain theory, and the new system economy theory. Experts' argumentations were used to confirm the design and the plan. With the recommendation of the Ministry of Health, Gongming Street of Bao'an District in Shenzhen was selected to be the experiment sample to carry out intervention experiment. Field supervision and direction, key informant interview, questionnaire interview and field evaluation were used to analysis the reform. The design was revised and complemented with information feedback.Field interview was used to investigate the data of the units, and key informant interview as the complement to find out the effect of the reform. Field test was used to evaluate the reform effect in the experiment unit. RESULTSa) Set up the new management system and operational mechanism of CHS.The CHS management center is the main body to manage the CHS units. And it takes on the function to supervise and manage all the units in the district.Developed the personnel reform and implement engagement system over all staff. Changed the distribution way and substituted it for the performance assessment method. Reformed the financial mechanism and separated the revenue and payout. Constructed logistic mechanism and management on medicine acquisition. Put into practice of the democracy supervision mechanism to monitor the work of CHS.b) Established the new CHS serving pattern.Set up the "GP serving team" to provide whole service for the resident, which was made up of one GP, one community nurse and one to a half pubic health physician. Changed the behavior and improve the diagnose ability of the doctor. Set up the system of "seeing a doctor" first in CHS and consummate the "bio-transfer-diagnose" mechanism.c) Developed a series of regulations that fit to the new management system of CHS to guarantee the sustainable development of community health service.d) Evaluation study was carried out on reform effect by field test. As it is only a half year after the reform when the evaluation began, the future effect of some regulations can't be observed. The results show that the rate of disease management has been improved, the ration of E/C changed significantly, the fee-for-outpatient has dropped and the satisfaction has improved.CONCLUSION AND RECOMMENDATIONSIn this research we constructed the organization and management system and the adapted regulations, and test the feasibility and maneuverability through the intervention experiment. The results of qualitative and quantitative analysis show that the design is scientific and can ensure the CHS to serve people much better.The conclusion is that the organization system and the regulations of the project design can bring the action change of the unit. Through exerting the personnel reform and performance assessment in the experiment unit, the local GPs have devoted more than before to complete the public health items, such as chronic disease management, prevention and health care and so on. The mechanism of "seeing a GP first in the community" and "bio-transfer-diagnosis" is running well. The fee for service per person-time has dropped. And the extent of patient's satisfaction in whole in the experiment unit is higher than the controlled one.The recommendations are as follows: Firstly, define the responsibility of the government. Secondly, keep improving and advancing CHS operation mechanism.INNOVATION AND LIMITATIONInnovation:a) For the first time, we constructed the new management system, service mode and five operation mechanisms based on such regulations and theories, as relevant law and rules, organization behavior theory, system design, system theory and cybernetics, and logistics system and delivery chain theory.b) We bring the scheme which has been constructed into effect. And through the intervention experiment we test the feasibility and maneuverability. The field test was used to evaluate the reform effect.c) A series of management systems we developed through the study were adopted by the Department of the Women and Children & Community Health Service of Ministry of Health of the PRC, and were put into effect in 29 cities which were CHS key engaged cities. The method and the results about improving the personnel technical ability and constructing the system environment have been applied to 13 experimental districts in 10 cities. And 8 papers have been published.Limitation:As it is only a half year after the reform when the evaluation began, the future effect of some regulations can't be observed. And for only choosing one place as the experiment unit, it still needs to be considered the different economic level and policy circumstance in different areas when disseminating the reform fruit to the whole country. More attention shall be paid to all these limitations in further study.