Study On The Equality Of Essential Public Health In The Perspective Of Universal Health Coverage

[Objective] Based on the perspective of universal health coverage,a theoretical framework of equity of public health services was constructed to provide a theoretical tool for the evaluation of the fairness of essential public health service system.Based on the theoretical framework,the status quo of essential public health services in China is analyzed,and countermeasures and ways to eliminate the factors leading to unfairness are explored to provide a multi-dimensional path for the government for improving the equity of essential public health services.[Methods](1)Literature research: Relevant literature and relevant policy texts publicly released at the national level are systematically collected about universal health coverage and basic public health service equity through CNKI and Web of Science literature database,which provides the basis for the theoretical basis and empirical methods of this research.(2)Qualitative and quantitative multiple demonstration: We logically summarize the content of the literature to clarify the key elements and key links that should be included in the realization of basic public health service equity based on the goal of universal health coverage,justice theory,and medical care justice theory.10 senior management experts from universities and health administrative management positions engaged in public health research were invited to participate in the demonstration results.(3)Spatial autocorrelation analysis: Coefficient of variation,Aikenson index and spatial autocorrelation analysis are used to analyze the differences in essential public health expenditure burdens in various regions,and Arc GIS software is used to draw agglomeration patterns to reveal the space mechanism of differences in the distribution of fiscal expenditure burdens.(4)Fair evaluation method: Lorentz curve,Gini coefficient,and Theil index were used to evaluate the fair distribution of public health workforce in service provision and the unfair contribution rate within and between regions.(5)Benefit attribution analysis: Concentration index,Kakwani index,and utilization need ratio are used to measure the distribution of benefits among different socioeconomic groups and analyze the benefits of policy target groups.(6)Regression analysis : Chi-square test was used to analyze the individual characteristics of different populations,and the disordered multi-class Logistic regression model and Tobit regression model were used to analyze the influencing factors of the use of different essential public health services for vulnerable populations.(7)Key person interview: The semi-structured interview outline was designed to conduct in-depth interviews with local essential public health-related practitioners to understand the causes of unfairness in practical work through interviews.The results of the interview can be used as the explanation,judgment and confirmation of the unfair phenomena in the provision and utilization of essential public health services.[Results] The results as following:(1)Based on the logical processes of beginning equity,process equity and result equity,a basic theoretical framework of public health equity was established,and the connotation and interdimensional of financial investment coverage,service provision coverage,and population health coverage were determined.The mutual mechanism is determined between the dimensions and the sub-dimensions within the dimensions.(2)The central government's special transfer payments accounted for 3.98%-10% of the total financing level of essential public health services in the east,60% in the central region,and 80% in the western region.The central government assumed the primary responsibility for financing essential public health services in the central and western regions.The local government has assumed the main responsibility for financing in the eastern region.Vertical equity is achieved in terms of financing responsibilities.In 2018,the Moran index of fiscal cost of essential public health service was 0.3208,which showed a homogeneous aggregation in the region.Among them,the low-value area in the northwest region was distributed,and the high-value area in the southeast region was distributed.The fiscal cost of the migrants is not the same as the regional economic development level.The matching is more pronounced in the eastern and western regions.The imbalance in financial input may lead to a further widening of the gap in essential public health services between regions and unfair health outcomes due to different levels of economic development in the region.(3)In the provision of essential public health services,there are imbalances in the distribution of service providers and service quality,as well as insufficient compensation for service costs.The Moran index of service agencies is-0.031,and the spatial coverage is balanced.The distribution of providers by population and economic development level is fairly fair.The Gini coefficient by geographical area is 0.67,which is very unfair.The difference mainly comes from the comprehensive influence between and within regions.In the eastern and western regions,the internal contribution rate to the difference is 65.12%.There is heterogeneity in the service content,service approach and service quality in various regions.There is a deviation between subsidies and service costs in various regions.The deviation index range for each region is-0.19-3.31,which is quite different.(4)The utilization opportunities of everyone is equal,but there are differences in the distribution of benefits,and different groups have different degrees of benefit.The lack of viability of vulnerable people affects their fairness of benefits.The concentration index of prenatal checkups and postpartum visit are-0.0067,-0.0041,indicating that people with low incomes have benefited.The Kakwani index is-0.4303,-0.4277.The subsidies have played a role in narrowing the gap between the relative rich and poor in society,reflecting relative equity.The concentration index of hypertension visit service and the health record services of migrants were 0.6018 and0.0333,indicating that high-income residents benefited from these services.The Kakwani indexes were 0.5798 and 0.2935,and the role of government subsidies is limited and relatively unfair.The benefits of vaccination services for urban and rural children are basically the same.[Conclusions] The theoretical framework embodies the core connotation of universal health coverage in every link of basic public health services from the beginning to the process to the result,and the mutual mechanism is obvious.It not only breaks through the fragmented research paradigm,but also provides a systematic and holistic research path.A series of system design re-optimization is needed to promote equity in essential public health services.The equity of fiscal cost in different regions will be promoted by improving the fair financing mechanism.The regional provider configuration plan is set in multiple dimensions to promote a balanced distribution and reduce intra-regional differences through comprehensive population distribution and geospatial factors.The equity will be improved in service provision by optimizing resources.The service heterogeneity should be improved from the system design,from increasing the adaptability of service content supply,improving the support of policies and systems,and ensuring the initiative of service provision.In order to incentivize service provision behavior,the optimization and selection of payment methods should be promoted.The public's willingness to participate should be increased in order to improve the fairness of service benefits.In order to promote the fairness of service results,we should improve their own health capabilities by empowering for vulnerable groups.[Innovation and Deficiency] The innovations in this paper are mainly as the following(1)A systematic theoretical framework of equity of essential public health has been constructed.The theoretical framework integrates the previous fairness elements of public service and breaks the previous fragmented research paradigm.On the one hand,it clearly reflects the integrity and systematizes of the starting point,process,and results of the essential public health service system.It also reflects a high degree of relevance to the meaning of universal health coverage.On the other hand,it is helpful to recognize the imbalanced objective differences in essential public health services,and the systematic and hierarchical differences were taken as the starting point for promoting equity.The internal logic and functional path of the theoretical framework provide ideas for subsequent related research,and the key variables of each equity element will strengthen the overall and systematic research of subsequent basic public health service equalization policy analysis.The framework can be used not only as a research framework,but also as an evaluation framework for monitoring the government's equalization process.It can also provide a multi-dimensional path for improving the equity of essential public health services.(2)The influencing factors of the unfair benefit of essential public health service utilization of vulnerable groups were analyzed based on the perspective of health feasibility.The research not only breaks the phenomenon of low health defense ability of vulnerable groups,but also turns to in-depth discussion on the substantive level of their low health capability.Strategies to improve the capability of the vulnerable groups to improve their essential public health services benefit and equity were proposed by the empowerment.It can provide a scientific basis for the government to improve the fair use of essential public health services for vulnerable groups.It has made innovations in the perspective of improving the fairness of results of universal health coverage.(3)In this paper,spatial global autocorrelation and local autocorrelation methods are introduced into the regional difference analysis of this study.Global autocorrelation is used to analyze the overall spatial distribution of elements and determine whether each element has spatial agglomeration.High-value and low-value aggregation areas can be found by local spatial autocorrelation.With the help of geographic information technology,quadrant maps are used to show the correlation and aggregation of regional equity elements.The research results reveal the spatial correlation mechanism of financing responsibility sharing,aggregation degree of resource coverage and the regional aggregation degree of public health service providers.It can provide a scientific basis for the government to make decisions on health regional planning and health resource allocation standards.Limitations of this study include(1)The key links and elements of equity in the system are fully considered in constructing the framework of this research.We must also consider the impact of the promotion of equity factors outside the system in the future.In terms of quantitative research,the data of service benefit analysis is only the national health service survey data of a city due to the limitation of data access,which can only represent the distribution of the city's basic public health service benefits.If the study continues,more city data analysis will be needed to more fully reflect the national situation.