Study On Two-Way Referral System Of Community Health Services In Xi'an

connection between the primary and secondary level of health care, has been adopted in many countries. It is well acknowledged internationally that the model of medical care service plays a key role in directing the distribution of patients, standardizing medical care procedure, controlling rising medical cost and maintaining the continuity, coordination and integration of medical care and etc. Community Health Services (CHS) commenced in the late 1990s in China.With the rapid development of CHS, the TWRS has been implemented in most cities and became one of the top priorities on the policy agenda for the reform of two-tier urban health services network. Although in recent years much progress has been made, the TWRS is still in its initial developing stages and there are some problems due to all sorts of constraints, such as inappropriate allocation of health resources, poor communication in referral activities, and etc. It was common that fewer patients during convalescent period were referred from hospitals to community health centres (CHC), to great degree which would restrict the development of CHS. That is to say, there was evident that the referral mechanism cannot operate smoothly at present. However, it was widely believed that the TWRS was not only one of the essential components of sustainable development of CHS, but also the key step of medical insurance reform for residents. Therefore, it is far-reaching to carry out the research on the TWRS in China.The paper aimed to explore the feasibility of the implementation of the TWRS and to develop the strategies for the TWRS via documenting the policy, administrative and institutional arrangements of the TWRS. The study was undertaken in Xi'an, which included both qualitative and quantitative research methods according to needs of different questions. First of all, literature retrieval and review were adopted so as to know the evolution and research on the referral system nationally and internationally. Questionnaire surveys and observations were conducted to investigate perceived health demands, needs and utilizations, as well as the evaluation in relation to the TWRS among community residents and medical practitioners both targeted CHS institutions and contracted hospitals. Meanwhile, in-depth interviews with 12 hospital and CHC managers were introduced to explore the performance problems and underlying obstacles. Secondly, such statistical models as multilevel analysis and logistic regression analysis were applied to seek for the determinants that underpin the practice and performance of the two-way referral mechanism. Lastly, the gap model was used to analyze the quality of CHS.The operation of the TWRS in Xi'an was described systematically in the paper. The results reflected clearly that more and more people who reported illness sought visiting doctors and the incidence of chronic disease became increasing, showed that health education was the most item of demand and utilization of CHS and the top three needs of CHS were systematical management of chronic condition, diagnosis and treatment of common diseases and physical check-up respectively. The study also demonstrated the feasibility and accessibility of the implementation of the TWRS in the current surroundings. What is more, the paper revealed the obstacles encountered in the practice, such as limited exertion of function in CHS, distrust on the quality of CHS, poor information transfer, lack of assessment mechanism, maldistribution of health resources, and so on. Key issues and policy implications were summerised and strategies to facilitate the development of the supportive environments and inter-organisational collaborations were also explored, which combined the experiences of other countries with domestic status.The research established a relationship model oriented three dimensions of the referral-related accountable entities including providers, consumers and party. In the model the critical issue was the inter-relationship between hospitals and CHC. Governments played an importment role of steering and regulating in the TWRS. The development of the TWRS needed to be considered as a system change rather than in terms of isolated instituational development. In addition, a theoretical framework shaped by five aspects of policy, clinician, resident, case and organization, in association with factors influencing the performance of the TWRS, could contribute to the programming on the sustainable development of the TWRS and CHS. Some of variable characteristics (age, sex, marital status, income, education, occupation, type of disease, infrastructure of CHC, speciality skill of hospital etc) significantly impacted the referral behaviour. Surprisingly, it seemed that the education background of doctors did not correlate with the referral decision. Comparing with previous researches, the analysis in the study mainly focused on the micro-level such as organisational and individual characteristics.These findings will guide the implications for both policy development and practice arrangements.