| BackgroundThe overall goal of basic health care system as a public policy system is to provide the people with secure, efficient, convenient and affordable health care services, and take the entitlement of basic health services to everyone. Nowadays, Over100countries included Britain, Germany and Japan have built the basic health care system. On April6th2009, China Government put forward《Opinions of the CPC Central Committee and the State Council on Deepening the Health Care System Reform》, and aimed to establish and improve the basic health care system covering urban and rural residents. Through establishing health care system, which included a public health service system, a health care service system, a medical security system, and a secured pharmaceutical supply system, the problem of "difficult and costly access to health care services" shall have been remarkably relieved, residents'rational health-seeking behaviors shall have been ensured, and residents'burden of medical costs shall be effectively reduced. Subsequently,《The State Council's Notice on Printing and Circulating the Recent Key Scheme for Implementation of Medicinal and Public Health Reforms (2009-2011)》 was issued, which pointed out that during2009-2011period, all levels of governments would invest total￥850billion on Health.At present, the prevalence of Hypertension in rural China is becoming serious, while the disease economic burden becoming heavier and heavier. A number of problems exist in the health-seeking behaviors of patients with hypertension, such as delay to see a doctor, low awareness of health, choosing high level medical institutions. Hypertension has become the major cause of rural residents'health and economic risk. The "four in one" basic health care system aimed to guide reasonable health care seeking behavior of patients and reduce medical costs through establishing system, financial compensation, and providing services etc. From2007to2010, the reimbursement rate of New Cooperative Medical System had been gradually raised, and the pilot counties of basic medicine system had been grew in batches. Also, the eight counties in Shandong developed the project "NCD community-base intervention in Shandong Province", which aimed to improve the health status of poor and vulnerable population, through establishing the two provided system of basic medical care services and basic public health services.Evidence-based decision-making in health develops along with the development of Evidence-based Medicine (EBM), and uses many methods of EBM. The research of health services management applied Evidence-based Decision-making, has been an international trend of health policy research and formulation. And the focus is that how to support the health policy localization with the complicated mechanisms and methodologies system of Evidence-based decision-making. Prevention and management of chronic disease is a litmus test for health-systems strengthening in low-income and middle-income countries [16]. From2005to2011, the basic health care system experienced the three stages of public discussion, laying foundation, and implementation. During the process, the health system establishing adhere to "basic","equalization", and "equity", So a question is put forward that if the development of health policy in eight counties of Shandong ensure the reasonable health-seeking behaviors and medical expenditure of patients?ObjectivesThe research taken the eight project counties in Shandong as samples is designed to study the impact of health policy elements on the health-seeking behaviors and medical expenditure among patients with hypertension. The specific objectives are as follows:(1) To explore the logical relationship among the basic health care system, health-seeking behaviors and medical expenditure control, and the systematic evaluation methods of health policy through theoretical analysis.(2) To measure and describe the rural health policy elements, health-seeking behaviors and medical expenditure of rural patients with hypertension, and the existing problems, to explore the influence of health policy elements on health-seeking behaviors and medical expenditure through empirical study.(3) To explore that how to establish scientific and reasonable health-seeking behavior of rural patients with non-communicable chronic diseases, and reduced unreasonable medical expenditure of NCDs through policy analysis.Data ResourcesThe resources of the study include the literatures and investigation. The literatures come from the library of Shandong University, including e-books, e-magazines, books and macroscopically health statistics data at provincial and national levels. The investigation datum roots in baseline investigation (2007) and terminal investigation (2010) of Shandong rural health workers training and chronic non-communicable diseases control program, including household investigation, institution investigation and informational interview.This study mainly used quantitative study methods, conducted two cross-sectional surveys of rural adults aged25and above in Shandong province using a multistage random cluster sampling strategy. In the first stage, eight counties were selected as study sites according to the geography and economic distribution; in the second stage, two townships were selected randomly within each county; in the third stage, two villages were sampled randomly within each township; in the fourth and final stage, all households within each selected village were listed and being selected randomly. In the base-line survey,16townships,40villages, and20087residents were sampled. In the terminal survey,1project township and1project village are selected randomly from each county. And4counties were selected randomly from the8counties; within these4counties, a non-project village was selected randomly from the selected project township as control village. In the terminal survey,12townships,14villages, and6216residents were sampled. MethodsBased on literatures review and experts consultation, this study constructed the logical framework among the basic health care system, health-seeking behaviors and medical expenditure, the rural policy indicators system of the "four in one" basic health care system, and the series indicators of health-seeking behaviors, compliance behaviors, medical expenditure and health consciousness, etc. All the indicators are sorted by levels, county level, village or township level, and patient level. This study chose the health care utilization model put forward by Andersen [171] in1968as the theoretical framework. The study applied the Hierarchical Linear Model (HLM) to analyze the impact of policy variables on the health-seeking behaviors, compliance behaviors and medical costs among patients with hypertension, with controlling the influence of other confounding factors, such as demographic, socio-economic and physiological factors, etc.The study methods included systematic analysis, literature review, expert consultation, and multivariate statistical analysis method, etc. Data analysis was conducted using EXCEL, SPSS, and HLM software.Results and findingsThis study constructed the logical model among various policy elements of basic health care system, health-seeking behavior and medical expenditure using health policy theory, and measured rural health policy and patients'health-seeking behavior using quantitative method. The study also across-the-board evaluated the impact of rural health policy on health-seeking behavior and medical expenditure using HLM, controlled for regional economic levels, patient-level socio-demographic variables, and illness characteristics (e.g., hypertension complications). The study screened out the relative sensitivity policy factors affecting patients'behavior and expenditure, established the interaction mechanisms of the three and the policy-oriented model of health-seeking behavior and medical expenditure. This study explored the quantitative methods of health policy evaluation, and avoided ecological fallacy and atomistic fallacy. 1. The logical relationship among the three and the indicators system of rural health policyThe basic medical security system and the secured pharmaceutical supply system directly affect the patients'medical expenditure, in matching of improved basic medical care services system and basic public health services system. Health services indirectly affect medical expenditure, through influence patients'health consciousness, and health-related behaviors. The rural health policy indicators system included four categories:basic medical insurance elements (New Rural Cooperative Medical System, NCMS), basic medicine elements, basic medical care services elements and basic public health services elements. And the policy indicators in this study have good reliability and validity.2. The epidemiology of hypertension and development of health policy in sampled counties of Shandong Province(1) The hypertension prevalence of2011intervention group (38.7%) is lower than that of2007baseline population (44.3%) and that of2010investigated population (38.88%), and the differences were statistical significance (P<0.05).(2)①Basic medicine elements:Among the sampled counties, Ningyang, Shouguang, and Laicheng were selected as the first batch of pilot counties.②Basic medical insurance elements:During2007-2010period, the participation rate of New Rural Cooperative Medical System had risen to99.6%, and hypertension is brought into extend of reimbursement by project counties one after the other. The rate of outpatient reimbursement had been gradually rise and visit-wise submission for reimbursement had been the main submission mode among the sampled counties.③Basic medical care service elements: During2007-2010period, the average number of health workers, village clinics per thousand rural people and the government expenditure of NCDs per people had been raised gradually. The total number of village doctor training times, higher authority supervising times, the average score of hypertension knowledge of village doctor, and the responsiveness of medical care services system among intervention group are all higher than that among control group, and the differences are statistically significant except the difference of training times between the two groups.④Basic public health service elements:During2007-2010period, the scores of health education indicators such as media publicity, management indicators such as hypertension management and follow-up, and supervising indicators of public health services among intervention group are all higher than that among control group, and the differences are of statistical significance.3. The policy motivation and oriented model of rural health policy elements influencing health-seeking behaviors and compliance behaviors among patients with hypertension(1) Impact of basic health insurance or basic medicine elements on health-seeking behavior among patients with hypertension:①For patients with hypertension, more years of implementing general reimbursement incentives for chronic diseases and visit-by-visit submissions were associated with seeing a doctor at a low-level institution, such as township hospitals and village clinics; The reimbursement of expenses by NCMS in township hospitals and village clinics during2010is higher than that in other level institution.②The implement of basic medicine system, and higher NCMS reimbursement rate for outpatient services contributed to improving patient compliance.(2) Impact of basic medical care services or basic public health services elements on health-seeking behavior among patients with hypertension:①Higher average score of hypertension knowledge of village doctors within a village, develop of media educations and health lectures contributed to improving patients health consciousness of NCDs. More promotion materials per people and more hypertension follow-ups contributed to increase of patients'scores of hypertension knowledge. Also, more hypertension follow-ups were associated with higher patient compliance index.②Higher responsiveness of health services system, patients health consciousness of NCDs, and patient compliance index were associated with timely treatment. And higher responsiveness of health services system was associated to receiving medical services at a low-level institution.4. The policy motivation and oriented model of rural health policy elements influencing medical expenditure among patients with hypertension(1) Impact of basic health insurance or basic medicine elements on medical expenditure among patients with hypertension:①The increased of total medical expenditure of last year was associated with these policy elements:The implement of basic medicine system, institutions received medicine usually being township hospitals and village clinics, more years of implementing general reimbursement incentives for chronic diseases, higher reimbursement rate of outpatient services, and visit-by-visit submissions.②The increased of medicine expenses per month and reimbursement of expenses by NCMS were associated with these policy elements:The implement of basic medicine system, institutions received medicine usually being township hospitals and village clinics, and higher reimbursement rate of outpatient services.③The increased of actual compensation rate of NCMS was associated with these policy elements:The implement of basic medicine system, more years of implementing general reimbursement incentives for chronic diseases, higher reimbursement rate of outpatient services, and visit-by-visit submissions; And the increased of medicine expenses per month contributed to lower actual compensation rate of NCMS.(2) Impact of basic medical care services or basic public health services elements on medical expenditure among patients with hypertension:①More village doctor training times during2007-2010period, and higher patient compliance index contributed to the increase of total medical expenditure of last year. Higher average scores of hypertension knowledge of village doctors within a village and hypertension patient management rate contributed to the decrease of total medical expenditure of last year.②Higher patient compliance index was associated to the increase of medicine expenses per month, and Higher hypertension patient management rate was associated to the decrease of medicine expenses per month.③The decrease of NCMS reimbursement of expenditure was associated with these policy elements during2007-2010period:More village doctor training times, authority supervising times and less media promotion.5. Applying HLM in the evaluation of rural health policy effectsHLM was less applied in domestic the evaluation of health policy effects. This study applied the method to analyze the health policy elements, construct the multi-level regression model according to the data level and structure. The variances were decomposed into different levels, and the individual level random error become simpler. Through using HLM, the study achieved the goal of analyzing policy effects of different level, and avoided ecological fallacy and atomistic fallacy.Conclusions and recommendationsThe main conclusions are as follows:(1) Demand release is the direct effect of implementation of rural basic security policy for NCDs.(2) Policy combination is the key condition to form reasonable health-seeking behavior and medical expenditure among patients with hypertension.(3) Individual intervention is the necessary means to form reasonable health-seeking behavior and medical expenditure among patients with hypertension.(4) Policy evaluation is the essential instrument to ensure reasonable health-seeking behavior and medical expenditure among patients with hypertension.The main policy suggestions are as follows:(1) Strengthen the policy motivation of reasonable health seeking behavior:①expand the extend of reimbursement, and raise reimbursement rate;②intensify medicine distribution, and reduce the price of medicine;③reinforce the network of services, and improve service levels;④promote health education, and manage diseases systematically.(2) Make overall planning and give overall consideration for establishing basic health care system.(3) Strengthen the implementation ability of health units at the grass-roots level.(4) Constitute criterion of health policy measures and regulate actual operation.
|
PDF Full Text Request