Research On The Influencing Factors And Improvement Strategies Of Policy Objectives Of Basic Public Health Service Projects

BackgroundThe implementation of National Basic Public Health Service Projects(hereinafter referred to as "BPHP")had effectively promoted the equalization of basic public health services since 2009.However,it was found that the policy objectives of such projects as maternal and child health care and vaccination were well implemented,while the policy objectives of some projects such as chronic disease health management varied greatly among different regions and primary health institutions.There are still some substantive problems in policy implementation that have to be solved urgently.Owing to the complexity of public health problems,the relationship and mechanism between the supply and demand factors affecting the implementation of the policy objectives of BPHP in different levels are still not clear.There is no systematic integration of the analytical framework among influencing factors which hinders the comprehensive analysis of influencing factors and the improvement of policy research.Which factors impede the implementation of the policy objectives of BPHP,of which are the determining variables,and what is the relationship between supply and demand factors affecting the policy objectives?It is very important to clarify the logical relationship between key factors and remove the obstacles to achieve the goals of BPHP.ObjectiveThrough theoretical research and empirical analysis,the research explores the problems and influencing factors in implementing BPHP to put forward relevant policy recommendations.Specific research objectives include:(1)to analyze the situation and existing problems of BPHP in typical areas;(2)to identify the main factors influencing the implementation of policy objectives for BPHP;(3)to analyze the interaction relationship of influencing factors in the implementation of the policy objectives of BPHP at county and institutional level;(4)to put forward measures and policy suggestions to solve the key problems in implementing BPHP in China.Data and MethodsIn this study,Jinan City,Shandong Province was selected as a typical region.Data sources of this research included three parts.First part came from the performance assessment results of BPHP including the project policy objectives by 15 counties and 449 primary health institutions in Jinan City in 2018,as well as scores and deducted points of organization management and fund management.The second part,the key informant interview.A total of 35 persons as persons-in-charge and backbones of the health administrative departments and CDC at municipal and county levels,and primary health institutions were investigated as supply key insiders.90 outpatients at primary health institutions were investigated as demand key insiders.The semi-structured interview questionnaire was used for in-depth interview.Thirdly,BPHP related factors including demography,health resource and medical services on the level of county and primary health institutions were extracted from the health information system and health statistical yearbook.Firstly,performance assessment results of BPHP between counties and institutions are compared by ANOVA and Student-Newman-Keuls test,and the existing problems were summarized.Then,"structure-process-outcome" model and Anderson's health service utilization behavior model are integrated to the theoretical model.Literature research and grounded theory qualitative analysis were adopted to collect influencing factors,and establish the analytical framework.Finally,based on the analytical framework,the research selects the supply and demand variables as independent variables,and the policy objectives of chronic disease management project as dependent variables.Multilevel linear model,intermediary effect analysis and interaction analysis were used to verify the theoretical hypothesis.Results1.Status and problems of policy objectives of BPHP(1)There is a big gap between the project targets and policy targets with chronic disease health management project.The percentages of counties that did not meet the policy objectives of such projects as health records management,hypertension health management,diabetes health management and elderly health management were 100%,66.67%,73.33%and 86.67%,respectively.The distribution of institutional project work indicators was statistically different among counties.Maternal and child health care,disease prevention and control,co-investigation management and other projects have been achieved or exceeded policy objectives in all counties.(2)The scores of organization management for BPHP for county health ministry and primary health institutions varied greatly among counties.The average score of organization management on county level was 11.4(9-13.5),and the main problems were that system construction,coordination and problem rectification were not fully implemented;the average score of organization management in institutions was 8.13(2-10),and the main problems were that system construction and performance work were not fully completed.(3)The scores of fund management for BPHP were not deducted from county level,and the average score of the institution was 8.62(5-10)with a statistically significant among counties.The main problems were completed budget and irregular use of funds.2.Factors affecting the policy objectives of BPHPFirstly,this study constructed the theoretical model and analytical framework of influencing factors by integrating related health service models,and systematically collect the influencing factors.The influencing factors can be classified into two categories:the supply-side and the demand-side,among which the supply-side influencing factors included policy system(supporting policies,supporting systems,project design),resource guarantee(human resources,project funds,hardware and equipment),organizational guarantee(operation mode,departmental cooperation,information system);the demand-side influencing factors included propensity characteristics(demography,social structure,health beliefs),resources promotion(economic capacity,social organization),health needs(perceived needs,assessment needs,and effect evaluation).secondly,statistical models were used to identify factors affecting the policy objectives of BPHP.Multilevel linear model analysis showed that the policy objectives of health records management,hypertension health management,diabetes health management,elderly health management and other projects at the institutional level were affected by both the supply and demand factors on county and institutional level.Human resources(the number of nurses per 1,000 in counties,the number of public health workers per 1,000 in counties,and the number of general practitioners per 10,000 in counties),hardware facilities(the average number of primary health institutions beds in counties),project funds(the score of institutional fund management),organizational guarantee(the score of organization management in counties and institutions)and other supply-side factors were independently positive correlated with different project policy objectives;the number of target population per institutional public health doctor was independently negative correlated with four project work indicators.Among the demand-side factors at institutional level,effect evaluation(residents' satisfaction)was a positive factor for policy objectives of health records management;health belief(residents' awareness rate)was a positive factor for health records management and a negative factor for hypertension health management,diabetes health management,elderly health management.3.Study on the relationship between supply and demand factors.Intermediary effect analysis showed that demand-side variables such as residents'satisfaction and awareness rate had significant mediating effects in the process of supply-side variables affecting project policy objectives.Among the total effects of the supply-side variables,such as the number of target population per institutional public health doctor,the score of fund management,the score of organization management,and the doctors'satisfaction,the mediating effects of residents'satisfaction were 50.30%?73.09%,and the mediating effects of residents' awareness rate were 13.04%?71.90%.Interaction analysis showed that there was an interaction between supply-side and demand-side variables such as residents' satisfaction and awareness rate,in the process of health records management,hypertension health management and diabetes health management.Residents' satisfaction and awareness rate higher than the average value,can reduce the negative effect of the number of records per public health doctor affecting the policy objectives of health records management projects,enhance the positive effect of score of institutional funds management,and weaken the positive effect of doctors' satisfaction.Conclusion and Suggestion1.Systematic institutional arrangements are needed to solve the problems existing in the implementation of BPHP.The main problems of BPHP includes:(1)the systematic measures for the project construction are not fully implemented;(2)the guarantee elements are not coordinated;(3)the implementation of organization management is not in place;(4)the implementation of the fund management system is irregular.It is suggested that health administration should make systematic institutional arrangements,improve the project content design and performance assessment system reform,establish a dynamic adjustment mechanism for service packages,attach attention to the resource guarantee of human resources and hardware facilities among counties and institutions,strengthen the organization management and fund management of counties and institutions.2.Establishing the dynamic evaluation model is helpful to discover the problems in the implementation of project policy objectives and management work.Our research systematically arranged the influencing factors analytical framework of three dimensions from both the supply-side and demand-side.We also verified the applicability and validity of theoretical integration of "structure-process-outcome"model and the Anderson model in the field of BPHP research by empirical studies at the level of counties and primary health institutions.Our research can be used as the foundation of dynamic evaluation model construction.3.Multi-party coordinated mechanism which should be led by the government may enhance the efficiency and quality of BPHP implementation.The empirical study verified that both supply and demand factors have common influences on the policy objectives,and revealed that demand variables such as residents' satisfaction and awareness rate play important mediating and interactive effects in the process of supply variables influencing the policy objectives,and explored the effect paths and potential mechanisms between both side factors.The results suggest that the important role of demand factors should be emphasized.Innovation and Limitation1.The innovation of this study(1)Based on the service nature of BPHP,this study integrates the "structure-process-outcome" model and Anderson model,orders the index dimension from both supply-side and demand-side,constructs the analytical framework as a selection tool for influencing factors at different levels,which is methodologically innovative.(2)This study quantitatively estimated the interaction and intensity of supply and demand factors in the process of affecting the project policy objectives at county and institutional level,defined the direct path through of supply factors affecting policy objectives and the indirect path through demand-side factors.The important role and significance of policy intervention of demand factors in the implementation of BPHP were discussed.It is of universal significance for policy-makers at different levels to co-ordinate health resources,formulate interventions,and improve target measures.2.The limitation of this studyThere are a few limitations in extrapolating the results to other regions with great differences with Jinan.In the empirical analysis,it is hard to cover all the influencing factors involved in the analytical framework by collection at the level of county and primary health institutions.Because our research is a cross-sectional study,it cannot reflect the impact of time series,but also may have a certain impact on the promotion of methodology in our study.