| Objectives:One of its notable features, the high quality has always been requested in medical and health fields,and the quality problems of health service have also been included in the agenda of all levels of governments. Township health centers, as the knob in the third-class networks, play an important role in the rural health service. In rural poverty areas, health service quality of township health centers, whether or not been sustainablely improved, directly impacts on how to meet farmers'health services needs of degree, and also directly affects the health level of the majority of farmers. Over the past 10 years, intervention strategies have been performed on the health services quality improvement of township health centers in rural poverty areas, which was supported by B1 area of the eighth projects /support projects in the health. On the basis of these practice measurements and analysis of domestic and foreign relative literatures, this study will attempt to systematically summary the improvement strategies and tactics of health services quality in rural township health centers from the theoretical and practical points, and analyze the results of implementation and the influential factors. These will provide a reference for all levels of governments to improve the health service quality of township health centers in rural poverty areas in the future.Methods:(1)Literatures and content analysis: The relevant domestic and foreign research data were obtained by searching tools. 120 documents, about the problems of health services quality of township health centers in rural poverty areas, was statistic measured by the use of content analysis. (2)Experts consultation: The questionnaires for the spot survey and interviews outline were defined by experts consultation.The implementation strategies, tactics and influential factors, which were found during survey, were also consulted the advice of experts. (3)Nominal group discussion: Nominal group discussion were applied for the influential factors of rational use of drugs, the influential factors of the implementation effect of standardized clinical treatment, and the effective practice to improve the quality of township health centers in rural poverty areas. (4)Statistical description and statistical inference: The arithmetic average, frequency and rate were used for the relevant descriptive statistics. The hypothesis tests, such as the chi-square test, Cochran-Armitage trend test, Kendall's coefficient of concordance test were used for statistical inference. The feedback data on the health service quality evaluation were fitted the corresponding model by structural equation model. (5)The method of figure fishbone in operation research: The influential factors of improvement strategies and tactics on the health service quality were systemically sorted out and summed up by the method of figure fishbone in operation research.Results:The results were achieved by analysis of strategies and tactics of improvement of health service quality of township health centers and its relevant influential factors:(1)There has no uniform definition of health service quality up to the present. The conceptual framework of assessment and improvement of health service quality of township health centers must be clarified in rural poverty areas in future. (2)Besides the structure quality problems such as hardwares, the prominent problems were in the process quality to the present township health centers in rural poverty areas, including the lower trained personnel which caused lower diagnosis and treatment level especially lacking of basic diagnosis and treatment standards and the medical records writing standards, the abuse of drugs especially in antibacterias, hormone and vein infusion, the insufficiency of public health service, and so on. (3)The essential drugs and rational use of drugs strategy and tactics could be devided two parts which were internal and external intervention tactics by its derivation aspect and three parts which were capability, pression and impetus by its effect aspect. These included:①established leader organization;②developed relative knowledge handbooks;③continuous education and propagation of medical personnels;④involve the rational use of drug into regulation;⑤set up effective external assessment and monitor mechanism and adjusted the key point of assessment and monitor according to the situation;⑥cooperation with the cooperative medical schemes and medical finance aid to form composition of forces;⑦fully mobilized the independence and creations of township health centers to boost essential drugs and rational use of drugs strategy. The corresponding influential factors included: the economy of areas, medical stuff, patient, medical organization, macro-circumstance, drug supply, the mechanism of"medical reimbursement by drugs", medicine information, medical education and non-controlled factors, and so on. (4)The clinical treatment standard strategy and tactics included:①established leader organization;②constituted and implemented the clinical treatment;③educated by various specialty;④standardized medical records writing;⑤monitored the clinical treatment;⑥rigorously implement check system of township health centers;⑦technical communication;⑧multiple monitoring and information feedback. The first five influential factors of clinical treatment strategy included knowledge level of medical stuff, educational level of clinical treatment,treatment habit of medical stuff, whether or not putting the treatment quality and performance assessment together, patient's health consciousness.(5)The assessment results of the feedback of improvement of township health centers in rural poverty areas showed:①the general best qualtiy aspects included per inpatient cost, improved cure rates, satisfaction of residents;②the general better qualtiy aspects included accessibility of health education, timely vaccination rate of 5 vaccines, Maternal systematical management rate, drug cost per outpatient prescription, reasonable treatment rate, safety of treatment, norm of nurse shift, Omitting rate of the statutory infectious diseases, percentage of essential drugs in outpatient prescription, 2 and more antibacterial drugs use rate in outpatient prescription, meeting rate of inpatient and outpatient diagnosis, intact rate of facilities, norm of quality assessment, full-scaled rate of quality improvement, drug income percent in total income.③the general common qualtiy aspects included hormone use percent in outpatient, rationality of personnel, relative market share.④the general bad qualtiy aspects included delivery rate in the township health center, 0-7 children medical examination rate, vein infusion percent in outpatient, medical record writing(especial retained record writing).⑤the SEM showed the descending sequential influential factors were rational use of drugs, norm of quality improvement, treatment quality, quality of public health service, intact rate of facilities, medical record writing and rationality of personnel.Conclusions:The conclusion of this study are:(1)The assessment and improvement of health service quality should meet with medical criterion and satisfaction of residents. But now it must focus on medical criterion.(2)The core point of the assessment and improvement of health service quality is different in different countries even in different development stage in one country.According to township health centers of rural poverty areas, based on continuous improvement of structure quality such as hardwares, essential drugs and rational use of drugs and basic treatment standards should be put to the first now.(3)The final success of all strategies and tactics is based on PDCA cycle. The intervention tactics and emphases should be continuously adjusted according to situation.(4)"The guideline of assessment of health service quality in central township health centers"could effectively assess health service quality and direct the improvement.Suggestions:(1)Besides the education of drug for patients, medical stuff should be paid more attention to improve drug use of township health centers in rural poverty areas now. There are two important tactics. One is mechnism design to correct abuse of drugs by economy factors. The other is continuous education of essential drugs and rational use of drugs, which can correct the wrong habit of abuse of drugs and to impove the knowledge. (2)It is necessary to intervene the clinical treatment standards. The key issue is to establish national basic diagnosis and treatment standards of township health centers including medical record writing standard. To apply widely, firstly the treatment standards of familiar and excessive diseases should be defined according to different situation. The process can follow from a little to many, from facile to deep method and use appropriate education method accustomed to rural poverty areas. To improve effect of intervention tactics, adult study such as case study and practice should be more accepted.(3)The improvement strategies and tactics should be systematicall designed to form the composition of forces.(4)The grassroot health organization should exert mechanism innovation in health reform of rural health system.(5)All intervention should focus on"three forces"-capability, impetus and pression for the grassroot health supplier.Innovations and drawbacks of this study:1. Innovations of this studyIn this study, based on the practical work of health services quality improvement of township health centers in rural poverty areas over the past 10 years, which was supported by B1 area of the eighth projects / support projects, and combined with the domestic and foreign literatures analysis, the improvement strategies and tactics in health service quality were systematically summed up from both theory and practice points, especially in both essential drugs and rational use of drugs, and regulation of clinical treatment of township health centers in the rural poverty areas. At the same time, the influential factors and effects of implement strategies and tactics were also analyzed. The appropriate strategies and tactics were found. These could provide the reference for government at all levels to improve the health services quality of township health centers in rural poverty areas. This study also constructed the theoretical models for improvement of health services quality of township health centers in rural poverty areas by the methods of structural equation model. The key entry point for quality improvement was found and also was provided for the government and academics as a reference.2. Drawbacks of this studyThe health service quality of township health centers in rural poverty areas contains the very extensive contents. Therefore, the whole contents and all core strategies and tactics cannot be covered during the stage of my doctor degree. While improving the quality of health services is the process of PDCA cycle, the core of intervention point and the corresponding strategies and tactics will also vary with the improvement of health services quality of township health centers in rural poverty areas of China. Limited time, energy and financial constraints, this study was mainly based on"evaluation guide of health services quality of the rural township health centers". Although these contents were given a relatively detailed and deeply study, some key elements, such as service attitudes of non-technical services, may be left out. Only the satisfaction of the residents on this survey was involved. Therefore, the best way was to establish the conceptual framework of the assessment and improvement on health service quality by literature review and expert advice, and to construct the framework of core concept about health service quality of township health centers in rural poverty areas, and to identify their contents. In the end, these research results would play a role in the future longer time. In follow-up study, this should be a key issue to be resolved.In addition, this study only addressed the central township health centers in the central and western China's rural poverty areas. The quality characteristics and improvement strategy of health services in common township hospitals and more scopes were not involved. This is still need for continuous improvement and concerns.
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