| The overall goal of the health care system reform is to establish the basic health care system which provides people with equal public health services and basic health care services through government's leading roles and responsibilities in planning, supervision and regulation. Under this basic health care system, enhancing the rural health service network is crucial to achieve the goal of providing basic health services to rural residents. The reform requires for further completing the rural health care service network. The county-level hospital shall be mainly in charge of treating and saving patients with severe or acute diseases; the township health centres shall take the responsibilities of diagnosing and treating the commonly or frequently encountered diseases; the village clinics shall take the responsibilities of the administrative villages'diagnoses and treatment of general diseases and other services. Theoretically speaking, in rural areas the commonly or frequently encountered diseases should be treated at or under the township level hospitals, while the severe diseases should be treated at or above the county level hospitals. In rural areas, patients should be effectively referred to appropriate levels of health institutions through the three-tier health care networks, and rural residents'demands for basic health care services should be met in grass-roots health institutions, in accordance with the distribution of health resources. However, the over-use of the county level hospitals and the under-use of the township health centres become a severe problem because of the inequity and the imbalanced distribution of health resources between urban and rural areas. Moreover, a vicious cycle due to the insufficient input and the drain of patients in township health centres and the lack of flow system make it impossible to refer patients from the higher levels to the lower levels of the health institutions. To solve these problems, an effective flow system should be established in which township health centres play crucial roles in treating the commonly or frequently encountered diseases and patients should be guided to use the grass-roots health institutions for general diseases.Medical service flow is a process in which patients receive the health care services in a more appropriate institution than the initial one without affecting the clinical treatment and prognosis, including upward referral and downward referral. To set up a reasonable and effective flow system is one of the key approaches to improve the macro health care system. Through the rearrangement of the health care services provision by different levels of health institutions and the reallocation of the resources by patients, the structure of the health resources and the direction of the health input shall be effectively adjusted. The reasonable referral in rural areas is significant to solve the problem of over-use of county level hospitals and under-use of township health centres, to promote the reasonable allocation of rural health resources and to improve the access to basic health care services for rural residents.Most of the current researches focus on the referral between urban hospitals and community health centres, while little attention is paid to the flow system in rural areas. Therefore it is important to pursue the following questions:in the county-level and township-level health care institutions, what kind of and how much of diseases and services can be referred, what are the influential factors, what referral models can be used, how to set referral standards, and what policies and supportive systems are needed to establish the rural health care flow system.The general objective of this study is:through the study on the current situation of health care services in rural Shandong, describe the flow both of outpatients and inpatients between different levels, analyze what kind of and how much of the diseases and services can be referred, explore the influential factors of referral in rural Shandong and the models and standards for referral, propose the contents and methods of and the relative policies for the flow system in rural areas.Date and MethodsThis study used both quantitative and qualitative study methods. The study data are from two sources. One is the baseline survey for the project "Proper technologies and productions for rural areas". We selected Jimo, Pingyin and Jiaxiang as the sample counties. In every county, we selected county hospital, county traditional Chinese traditional medicine hospital, county maternal and child health hospital, four township health centres and four village clinics of each town. In all,3 county hospitals,3 county Chinese traditional medicine hospitals,3 county maternal and child health hospitals,12 township health centres and 48 village clinics were selected. We obtained the outpatient and inpatient medical reports of a specific period of the three levels institutions through the survey.The second part of the data is from the questionnaire survey of the experienced clinical doctors who gave their judgments on which level of the rural health institutions should the patients theoretically be referred to according to the medical records. We selected county hospital, county traditional Chinese medicine hospital and 6 township health centres respectively in Jiaxiang and Qufu County.2 county hospitals,2 county traditional Chinese medicine hospitals and 12 township health centres were selected in total. We interviewed the clinical doctors who work more than 10 years and have the intermediate technical titles in county hospitals and who have the highest qualification in township health centres.We used the Microsoft Access software to input data and the SPSS11.5 software to conduct the analysis. The descriptive statistical analysis and single factor analysis were the main analysis methods for quantitative data. The qualitative data were from the interviews of the managers of the sample institutions.Main results(1) 67.25% outpatients in the county-level medical facilities are supposed to referred to the lower medical facilities, and 23.15% inpatients in the county-level medical facilities should be transferred to the gross-roots medical facilities; Almost no patients in the township-level medical facilities are thought to be referred to the gross-roots medical facilities, and only 6.38% outpatients and 17.77% inpatients respectively; in the township-level medical facilities should be transferred to the superior medical facilities.(2) Diseases that should be primarily referred in the outpatient service were 24 diseases, such as acute upper respiratory tract infection, prenatal examination, gastritis, tracheitis, diabetes mellitus, general traumatic, vaginitis, herpangina, hypertension, early pregnancy, coronary heart disease, pneumonia, induced abortioneczema, gynecological examination, health examination, lumbago, urticaria, enteritis, menstrual disorder, hyperplasia of mammary glandsdermatitis, lymphadenitis, pelvic inflammation, diarrhea and urinary tract infections only 16.89% of these patients saw the doctors in township hospitals; the diseases should be transferred in inpatient service were about 15, such as normal delivery, all kinds of trauma, hypertention, coronary heart disease, chronic bronchitis, acute bronchitis, haemorrhoids, acute appendicitis, the upper respiratory tract, groin indirect hernia, induced abortion, cerebral concussion, anemia, chronic gastritis, tonsillitis and so on, which made up 50.43% of the common illnesses in the inpatient service, while only 20.86% of these diseases were treated in the township hospitals.(3)Among the top 15 diseases in the outpatient service visit, proportion of diseases considered to be treated in the township hospitals by doctors in county-level medical facilities was lower than the township hospital physicians, while in the top 15 diseases in the inpatient service visit, it's the same situation. Only the diseases vary largely in the severity and must according to the state of the disease to ensure the facility of the treatment, for instance, coronary heart disease and pneumonia, there was statistical difference, while statistically difference didn't exist in the much easily or difficultly cured diseases. Also,23.19% physicians in the county-level medical facilities didn't have the willingness to refer their patients to the grass roots medical facilities.(4) The medical expense of the common illness in the outpatient service in county-level medical facilities was obviously higher than that in the township medical facilities; however, there was no statistic difference; so was the medical expense of the inpatient services. There was significant difference in the medical expense of two kinds of diseases between county-level and township medical facilities, one kind was chronic non-infectious disease, such as hypertension, coronary heart disease and chronic respiratory disease, the other kind was the disease needing surgery, for example hemorrhoids, acute appendicitis, caesarean birth and hysteromyoma.(5) Outpatients supposed to be referred in the county-level medical facilities are 67.25%, while the service capability of the township medical facilities was only 48.45%; inpatients supposed to be referred in the county-level medical facilities are 23.15%, while the service capability of the township medical facilities was only 16.50%.62.39% respondents thought that the largest barrier to develop the service capability of the township medical facilities was shortage of the talent, among which 80.95% respondents believed that the key problem was too difficult to introduce high technology professionals.(6) As to the medical service referral model, most interviewees preferred to adopt the combination of more kinds of referral models. Main opinions included:according to the severity and recovery status of the diseases, to work out the referral standard of each level hospital and draw up the supervision, rewards and punishment system. In consideration of the limited service capability of the township hospital, the county-level medical facilities should take the responsibility to diagnosis, while the township medical facilities focused on more treatment work.Discussions and policy implicationsThere is large and potential room of referral for outpatients and inpatients in county level hospitals. During the policy formulation process, it is important to make it a policy goal that the outpatients in county level hospitals should be referred downward and guided to use the services in township health centres and village clinics.The main influential factors for referral in rural areas:(1) County level hospitals and township health centres are in opposite positions of interests and have cognitive gap in judgment of disease referral. (2) There are expense gap of similar disease treatment between county and township hospitals. (3) Township health centres are poor in service capacity. At the present stage, the medical service referral model for rural area could take into account the combination model of disease category and duration. In detail, in line with the prevalence of common illness and the service capability of all levels medical facilities, the standard of referral including the list of the diseases ought to be referred and the flow of the normal diagnosis and treat should be formulated. Meanwhile, the current situation that the service capabilities of the rural gross-roots medical facilities are relatively insufficient should be considered. The way we ought to take is that the diagnosis of the disease should be cleared by the county-level medical facilities, the proper level of the medical facility the patient should be treated ought to be decided by the physician of county-level medical facilities, and the treatment scheme should be formulated by the county-level medical facilities and implemented by the township medical facilities to assure the treatment effect.As to this study, we propose the policy recommendations as follows (1) Health departments in various regions should ensure the main referable disease and their normal treatment flow and the referral standard, which strictly obeyed by the medical institutions and the clinical doctors to refer the patients in time. (2) Further to clear and definite the function of the medical service system in rural areas. More work on diseases diagnosis and treatment scheme should be assumed by the county-level medical facilities, while more work on cure and recovery in the following period after the treatment scheme has been drawn up ought to be taken on by the township hospitals. (3) Strengthening the construction of the health care service system in rural area, including the construction of institution and capability, especially the ability building of the service personal of grass-roots medical facilities; by means of institutional arrangement to replace the fully competition relationship with coordination among the three-level medical facilities for the purpose of solving the contradiction of economic interest among all-level medical institutions. Strengthen the establishment of medical service flow system in rural area and impel the medical facilities and physicians to abide by local referral disease category and treatment flow to copy with patients, guided by the medical service referral to adjust the health care resource allocation, in accordance with the decided referral disease category, treatment flow and cure requirement to allocate the workers and equipments to various-level medical facilities. (4) Enlarging the gap of deductible and reimbursement ratio between county-level and township medical facilities, and the gap is 20% at least. (5) Establishment of system related, including the construction of supervision and assessment mechanism to ensure the accomplishment of flow. In line with local referral disease category and normal treatment flow to enhance training of corresponding disease knowledge and service ability in grass-roots medical facilities to improve the capability of accepting the referral case in grass-roots medical facilities. Increase the supervision for the quality of grass-roots medical facilities, for instance, supervising and accessing the effect of the following treatment of the referral disease category to make sure that patients can acquire the similar treatment effect in different-level medical facilities.
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