Study On The Performance Evaluation Of County Health System In Central And Western China

Purpose of the StudyThe study tried to explore and identify concept for county health system throughin-depth interview,system analysis,and Delphi method on the basis of literature review.Performance evaluation framework and indicator system were established,of whichindicator system was refined through field verification.On the basis of theoretical research,the study also discussed ways to develop performance evaluation tools,set up performancereview mechanism and enhance management over county health system,and offered policysuggestions on these areas.MethodologyThe methods used in this study include Literature review,System analysis,In-depthinterview,elphi method,Expert discussions Field verification and statisitics analysis,such as Chi-square test and principal component analysis.A number of specialists on health administration,health economics and social medicinewere consulted through Delphi questionnaire on performance framework,evaluationprinciples and evaluation indicators targeting county health system.2 rounds of Delphiconsultations were conducted,findings of which served as importance reference forindicator selection in the first and second round respectively.4 sample counties were chosen in the study to assess county/district health systemperformance with"field verification indicator system".Comparison was made againstfindings of expert evaluation to verify validity of the indicator system.Indicator system was further refined upon availability of field investigation data,submission format of indicatorsin statistical report,quality verification of acquired data,feedback from county healthbureau staff in obtaining information against indicators and expert suggestions.Outcomes1.Definition and performance framework for county health system in central and westernChinaCounty health system is defined as an integral within county administrative jurisdiction,which serves to safeguard and promote health of local residents,and interacts with healthservice supply side and demand side,as well as social economic context in the county.Thecounty health system is composed of 3 subsystems-health service management,healthfinancing and disbursement,and health service delivery.A general goal of county healthsystem in central and western China is to establish health service system in line with socialeconomic development and health needs in the county,so as to deliver equitable,efficientand quality health services to residents in the county and improve health status of people.2.Performance and its evaluation of county health system in cetral and western ChinaPerformance evaluation framework proposed in the study works on county healthsystem as an integral,and conducts assessment through a third-party agency or supervisinggovernment agencies.Performance of county health system is measured against fulfillmentof this general goal.The study based itself on health system performance concepts initiatedby WHO and experts including Rifat Atun,and proposed performance framework forcounty health system upon characteristics and priorities of China's rural health.Focusingon function,output and outcome of the county health system upon interaction between 3sub-systems and health service users,the study explored 7 dimensions of performance-health service quality,health service efficiency,health equity,health risk protection,healthstatus improvement,financial risk protection,and satisfaction on health system among localresidents and health workers.3.Performance review indicator system for county health system in central and westernChinaThe study launched a result-oriented evaluation targeting county health system in central and western region,and worked out a performance review framework consisting of1 primary indicator and 7 secondary indicators.By standard of completeness andavailability,72 preliminary tertiary indicators were proposed under the performance reviewframework.Consequently,26 tertiary indicators were chosen through Delphi method,expert consultation and analysis of objective date in 40 HealthⅤⅢcounties,to make theindicator system scientific,representative,workable,dynamic and with guidance functions.Weight distribution and reference value were then identified accordingly.Primary indicators in the indicator system consist of"output"and"outcome"."Output"can break down into 4 secondary indicators-health service quality,health serviceefficiency,health equity and health risk protection;"outcome"can be reduced to healthoutcome,financial risk protection and satisfaction.Tertiary indicators include:share ofvillage clinics using essential drug list in the township(town)(%);compliance of disposalinjector disposal in township health centers(%);coverage of cure among inpatients intownship health center(%);coverage of qualified village clinics(%),share of institutionaldelivery(%);coverage of national planned immunization program among 0-1 children(%),bed utilization rate in township health centers(%),ratio of medical expenditure out ofconsumption expenditure between rural residents and urban residents,availability of villagedoctors and health workers per 1000 rural population;availability of township healthtechnicians per 1000 rural population;availability of beds per 1000 population;number ofhealth technicians per square kilometer,two-week visit rate by NCMS insurees(‰),coverage of sanitary toilet in the countryside(%),coverage of tapping water in thecountryside(%),iodine salt intake compliance among local residents(%),share ofinterviewees with no or false knowledge on AIDS among above-15 residents(%),recoveryrate under DOTS program(%),infant mortality rate(‰),maternal mortality rate(/100,000),under-5 mortality rate(‰),aggregate incidence of Class A and Class B communicablediseases subject to mandatory reporting(/100,000),share of endemic patients among totalpopulation in the jurisdiction(/100,000),actual share of reimbursement by NCMS,comparison on actual reimbursement rate between MFA-aided NCMS insurees andnon-aided insurees,overall satisfaction rate on acquired health services by patients,andsatisfaction rate by health practitioners at township and village level. 4.Application of the evaluation indications systemObjective data information in the indicator system was collected from nationalstatistical reports with good quality and high comparability.For indicators subject to fieldmeasurement,consistent and concrete assessment guidance was developed to minimizesubjective deviation.The indicator system can be used to conduct vertical comparison toshow changes of performance in counties,horizontal comparison among different regions,as well as in-depth analysis and comparison on specific dimension,thus generatingevidence for intensive analysis of performance determinants of county health system.Theindicator system will help decision makers and health managers to understand the positionof a specific county in the whole province,and even in central or western region in terms ofhealth system performance,so that they can better allocate financial resources,enhanceeffectiveness of resource use,and contribute to higher cost-effectiveness for county healthsystem setup in central and western China.2.2 Verification of the indicator systemThe study chose 2 counties each from a central province(Shanxi) and a westemmunicipality(Chongqing) as samples for field investigation."Questionnaires for countyhealth system performance review indicator system for central and western China"wasissued to the sample counties to collect information on health system performance in 2006and 2007.In the meanwhile,experts were recruited to conduct comprehensive evaluationon the sample counties from 5 aspects-function delivery,service quality,service efficiency,impact on medical burdens and service utilization,as well as assessment by local residentsand health practitioners.It was found that findings generated by the indicator system areconsistent with those by expert evaluation,showing that the indicator system is reliable inshowcasing county health system performance in central and western China,and can serveas a"ruler"for evaluation by competent health authorities.Conclusions and Recommendations1.Comparison between therotical framework and practical frameworkBoth of the frameworks are multi-dimensions.The therotical ones are more macroscopicand it pays attention to the whole process including the inputs,outputs and outcomes.The pratical framework of each coutry is based on different kinds of therotical framework andmodified according to the real situation of the country.The practical ones usually onlyconcentrate on the outputs and outcomes and less on the routes of performancemanagement.Compared to the therotical frameworks,the practical one's aims are moresimple and straighe and its indicators are more available.2.Comparision of indicators between China and other countriesWhen we look at the indicators systems of other countries,we find that nationalgovernments play very important roles on making the indicators and provide importantpolicy reference and supports for the dynamicity of the indicators.This makes theindicators being adopted thoughtout the countries.Since the health information system inChina is still need to be perfect and the data of some indicators cannot be gotten continuely,the dynamicity and the practicality of the indicator in China still need improvement.3.dynamic counting method of the indicatorsFor those indicators that are more sensitive and fluctuated frequently between years,we may try to use an synthetic counting method as:the score of one indicator= weighingcoeffientx("score compared with the standard values"+"score compared with the value oflast year")。There are in total 10 indicators out of the indicators systems can use suchmethods.4.The indicators illustrates the characteristics of county health systems in central andwestern China.Unique position of county health system was considered by the indicator system-having rural health as the focus and serving to promote balanced urban-rural development.Health resources allocation was assessed for both rural population,and all permanentresidents in the county.In the meanwhile,indicator on health resources coverage wasdeveloped to reflect less-dense demographical picture in central and western regions.Thestudy also worked out an indicator on"satisfaction among township and village level healthworkers",to shed light on sustainability on county health system.Mean value of indicatordata in central and western regions as well as indicator data on some surveillance sites incentral and western regions were used as reference value.Such arrangement not onlyreflected specific features of county health system in central and western regions,but also mirrored the policy incentive for performance improvement of county health system.5.Those indicators can contribute to scientific management and better performance in thefollowing ways:(1) Navigation.(2) Differentiation.Performance review will highlightvertical and horizontal gap.By understanding the gap and challenges,the counties can workout targeted measures,to upgrade operating mechanism and management system,and driveforth sustainable development of the whole health system.(3)Management.6.Establish performance evaluation mechanism for county health system.Performance evaluation shall be a consistent item in the agenda,built upon availableindicators and suggestions from experts and grassroots health managers.The studyrecommended that further study and experiment be conducted to fine-tune indicator system,explore appropriate evaluation cycle,develop relatively stable analytical pathways,andwork out a set of scientific and sound evaluation tools which can be applied by the countygovernment.Furthermore,through some policies or regulations,performance review can bemainstreamed into the evaluation of county health system,to create incentive for enhancinghealth administration in the county.Research innovationThis study invented county-specific health system performance review indicatorsystem targeting central and western China.The result-oriented indicator system helps toassess output and outcome of health system operation,and reveal the most direct outcomesin health system.Health administrators,at county level in particular,can make effective useof data generated through the system,to analyze weak links and problems in health systemsetup,and identify areas in need of more attention and better management.Laying eyes on specific characteristics of county health systems in central and westernChina,the study worked out a scientific yet practical indicator system on health systemperformance review,which can generate evidence for health system building and healthmanagement decision-making at county level.