| Background"Opinions of the CPC Central Committee and the State Council on Deepening the Health Care System Reform"pointed out that "guide general diagnosis and treatment down to grass-roots medical institutions,and gradually achieve the goal of the first-diagnosis",so far the pilot reforms of the first-diagnosis at the grass-roots level has been carried out in many areas in China.Ji'nan has made some achievements through guiding residents'primary care through differential payment of medical insurance,two-way referral,training general practitioners,and establishing a medical consortium.However,there are still some problems such as disorderly seeking medical treatment and relatively backward ability of primary medical service.It is necessary to make a systematic investigation on the service supply ability of primary medical institutions,the cognitive level of residents and medical personnels at the grass-roots level,and the overall quality of the leaders of primary medical institutions,so as to understand the problems existing in the implementation of first-diagnosis system in Ji'nan.This study is significance to further improve the implementation effect of first-diagnosis system in Ji'nan.ObjectivesThe objectives of this study were to investigate the implementation status of first-diagnosis system in Ji'nan city,explore the existing issues and imperfections during the operation of first-diagnosis system and put forward corresponding countermeasures to improve the implementing effects.MethodsThe Health Statistics Bulletins(2015-2017)of Ji'nan city were collected and analyzed in this study.According to the multi-stage stratified random sampling method,a total of 58 primary medical institutions were selected from 335 primary medical institutions in Ji'nan,and a questionnaire survey was conducted among community residents and medical staff.According to the proportion of total consultation and treatment in each of 8 districts or 3 counties of Ji'nan city,127 primary medical institutions were selected from 335 primary medical institutions by random sampling method.A questionnaire survey was conducted on the spot among the leaders of 127 primary medical institutions.And 1 leader of each district/county was randomly selected for in-depth interviews.In this study,a total of 1027 residents,544 medical personnels,127 leaders of primary medical institutions and 11 in-depth interviewees were investigated.The statistical descriptions using of this study were expressed using rate or composition ratio.The differences of,rates or composition ratios among different groups were tested by Chi-square test.Results1.The current situation of primary medical institutions in Ji'nan.According to the data of Ji'nan Health Statistics Bulletin(2017),The primary medical service supply showed a downward trend(the total number of primary medical institutions had decreased by 2.6%,and the number of hospital beds had also decreased by 4.1%,of which the number of beds in township hospitals had decreased by 14.4%);shortage of medical staff and low educational level(the number of primary practitioners accounted for 51.0%of total health technicians,and technical secondary school graduates accounted for 72.3%of all);technical titles of medical personnels were severely low(junior technical titles and below accounted for 69.2%).Ji'nan owned 713 general practitioners in total,there was just 1 general practitioner in every 10 thousand residents.According to the survey,at the grass-root level,the hardware facilities were weak and provision of essential drugs were incomplete.There were only 46.6%of primary medical institutions had equipment that meets basic medical needs.The median number of equipped national basic medicine types was 247(equipping rate was 47.5%).2.The implementation situation of first-diagnosis system in Ji'nan was not satisfying.According to the Ji'nan bulletin,in 2017,there was no fundamental change in the pattern of preferential choice of hospital for residents(the total number of outpatient visits in hospitals increased by 8.5%year-on-year,in primary medical institutions increased by 7.3%year-on-year;The number of hospital discharges increased by 9.8%year-on-year,while that of primary medical institutions decreased by 2.2%).The total number of patients treated in the secondary and above level hospitals accounted for 48.5%of the city's total,while the proportion of primary medical institutions was 43.5%.According to the survey,residents' satisfaction rate at the grass-root level was only 25.2%,and the reasons for dissatisfaction were mainly due to the lack of benefits from the first-diagnosis system(83.7%),inadequate policy propaganda(75.3%),and no actual effect(27.1%).3.The cognitive level of the first-diagnosis system was uneven.The understanding of the first-diagnosis system was superficial,and the cognitive level was uneven.According to the survey,the awareness rate of first-diagnosis system of medical personnel at the grass-roots level was 83.7%,and of Ji'nan residents was 65.5%.Medical personnel's cognition of the first-diagnosis system was 61.2%,that of Ji'nan residents was 62.7%.But 50.4%of the medical personnels were uncertain about the improvement effects on the current medical treatment order at the grass-roots level,55.7%of medical personnels believed that the implementation effect of first-diagnosis system was not satisfying.The satisfaction rate of Ji'nan residents on first-diagnosis system was only 25.2%.There were significant differences of the residents'cognitive level in some terms of demographic characteristic,included age,educational background and occupation(P<0.05).There were significant differences of the medical personnels' cognitive level in some terms of demographic characteristic,included age,major and technical title(P<0.05).4.The overall quality of the leaders of primary medical institutions was poorQuestionnaire surveys indicated 39.7%of the leaders had college or technical school educational background,4.8%majored in management,48.4%had engaged in management for more than 10 years,27.8%were full-time managements,82.5%were low-income people(<50,000 RMB/year),and 44.4%with 10 or more years of work experience.In-depth interviews showed that the leaders entrenched the old management ideas,generally lacking of experience in management and policy research.In addition,some part-time managers were limited in energy,which led to low initiative and efficiency.As a result,more than 90.0%of the primary medical institutions at the grass-roots level did not achieve effects on first-diagnosis system.Analysis showed that there were significant differences in gender,income,and educational background between the leaders of township hospital and community service centers(stations)(P<0.05).SuggestionsAs to the above problems,we offered the following four suggestions:i,Strengthen the policy propaganda and guidance of different groups of people,improve the policy supporting system,raise the awareness level of residents,medical personnel and the heads of primary medical institutions on fiirst-diagnosis system,and improve the fulfillment of residents at the grass-roots level on first-diagnosis system.ii,Consolidate the construction of basic hardware facilities,enhance the level of primary medical services,increase the training of the number and quality of general practitioners,and implement family doctor contracting services.iii,Establish a primary medical incentive mechanism for medical personnel at the grass-roots level,rationally allocate the heads of primary medical institutions,and strengthen the management capacity of the managers.iv,Effectively implement a two-way referral system,and ensure the supply of essential drugs. |
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