Equality Analysis Of China Urban-rural Health Workforce Distribution And Comprehensive Assessment Of Its Intervention Strategies

The inequality of urban-rural health human resource distribution is prevalent in the world. Health workers tend to work in urban and affluent areas rather than rural and poor areas. Due to the urban-rural dual economical structure, most of the resources are concentrated in urban areas. Human resources for health, as most important part of health resources, are also concentrated in large hospitals in urban areas. To solve this problem, Chinese government has developed a lot of incentive policies and interventions. The unfair situation has improved than before, but it is still a shortage of health workers in rural areas.In the first part, it was to identify whether policies in different stages of medical system reform had been effective in decreasing inequalities and increasing the density of health worker in rural areas in China between 1985 and 2011. With data from China Health Statistics Yearbooks from 2004 to 2012 we measured the Gini coefficient and the Theil L across the urban and rural areas from 1985 to 2011 to investigate changes in inequalities in the distributions of health worker, licensed(asistant) doctor, and registered nurse by states, regions and urban-rural stratum and account for the sources of inequalities. We found that the overall inequalities in the distribution of health worker decreased to the lowest in 2000, then increased gently until 2011. Registered nurse was the most unequally distributed between urban-rural districts among health worker. Most of the overall inequalities in the distribution of health worker across regions were due to inequalities within rural-urban stratum. Apart from the policies of national reform, contextual factors influencing inequality of urban-rural health human resources were urban-rural ratio of water supply coverage, proportion of government health spending in national health expenditures and urban-rural ratio of per capita health care expenditure. Therefore, different policies and interventions in different stages would result in important changes in inequality in the distribution of health workforce. And it was also influenced by other system reform, like the urbanization, education and employment reform in China.In the second part, based on evidence-based medicine, we searched many data bases, such as, Pub Med, Web of Science, WHO and the World Bank website, VIP CJFD and China Academic Journals Full-text Database(CNKI) with “health workforce”, “medically underserved area”, “rural health service” and “incentives” to find the effects of intervention projects to increase health workers in rural areas in developing countries. We developed strict inclusion and exclusion criteria, through screening, final confirmed eight intervention projects detailed results, mainly in Africa(South Africa, Niger, Senegal, Zambia), Southeast Asia(Thailand, Indonesia) and South America(Chile). Through data extraction and analysis system, we found these researches were generally cross-section research, longitudinal studies and survey research. The main interventions included financial incentives, mandatory service, continuing education and flexible service agreement and so on. Further analysis showed financial incentives, mandatory services and education programs are three basic intervention strategies. The different design and combination of intervention strategies would result in different effects. The design of these interventions must adapt to different conditions in various countries. Meanwhile, the implementation of the intervention effect was affected by the specific project environment.In the third part, it was to examine the importance of different attributes when the final year medical students from different qualified colleges and various social conditions in China made job choices according to the present incentives. The final year medical students between famous “211” colleges and ordinary colleges in Shaanxi province were given a discrete choice experiment that elicited choices for attributes of possible job listings. Job attributes included salary, location, housing provided, financial allowance, length of service, education opportunities and career development. Conditional logit models were fit for the information to calculate stated preferences and willingness to pay for attributes. And it investigated variations in choices between medical students between famous “211” colleges and ordinary colleges.We found information were gathered from 51 medical students in a famous “211” college and 99 medical students in an ordinary college. Medical students from both groups had equivalent large willingness to give up salary in trade for working in urban areas. And their selection of work posting was highly affected by increasing salary. As compared to medical students in famous “211” colleges, medical students in ordinary colleges had higher preference for housing provided and the possibility of more further education. Therefore,Medical students with rural background from ordinary colleges were most likely to be attracted by current incentives in Shaanxi province. And the three most important factors they consider in accepting postings to rural areas were money incentive, housing provided and possibilities of more further education.In the fourth part, according to the above analysis, we give the following policy recommendations:(1) to develop the rural economy and the infrastructure in rural and remote areas of;(2) to develop different incentives depending on the circumstances;(3) to develop the compulsory service policy for health workers to work in rural areas; and(4)to increase the supply of health workers through enrollment in medical education;(5)to improve orientation training system for human resources for health in rural areas.The results are useful for the Chinese government to decide how to narrow the gap of health workforce and meet its citizens’ health needs to the maximum extent.