Study On The Resource Allocation Of Public Health Care Services In Community Of Shanghai Based On Equalization Perspective

[Background]Obviously, equalization of basic public services (BPS) has become one of the most concerned problems in China’s current economic and social research field. Market failure, as a common problem in provision of BPS, needs to be solved by the government through strengthening the basic construction of public service system. To solve this problem have important significance in social justice safeguarding, as well as the promotion of residents’ consumption and national economy. For a few years, equalization of basic public services (EBPS) has been the main work of administration in China and taken as the way to construct a service-oriented government. Study on EBPS would provide powerful support theoretically and practically for service-oriented government’s construction. Undoubtly, it is the favorable political opportunity to help the formulation of relevant policies.The equalization of basic public health services (EBPHS) belongs to the category of EBPS. As one of the main goal in our new round health reform, EBPHS is consistent with the objective of service-oriented government’s construction. In the concept of EBPHS, health policies’ research context has changed. In order to carry out scientific research design and propose countermeasurable policies, the research direction in this new concept must be complied with properly.All-level governments of Shanghai always attached great importance to community health service (CHS), which was regarded as a civilian-service project with a characteristic model. However, in the new perspective of ’equalization’, regional basic public health service capability gaps and problems are clearly exposed. To solve these problems, calls for the policy-adjustment from the resources allocation to the municipal planning and other aspects of policy. Most of the current researches are aimed at part of the complicated problems, lack of comprehensive analysis or strategy which would address the systematic problems accompanied by EBPHS. "In2015, the mechanism of achiving EBPHS should have be established gradually", this has been proposed as one of the goals in the health reform’s Twelfth-Five-Year Plan of Shanghai. In current policy environment, there is an urgent need for the research of EBPHS to guide Shanghai city’s health reform practice. In addition, it is obvious that other districts in China would face similar problems in the process of realizing equalization community basic public health services (ECBPHS), hopefully, findings and experiences sumed up in this study might benefit them. Based on these considerations, the author belives that this study would serve the health reform of Shanghai both practically and academically.[Objectives]Empirical researches on the environments and integrated frameworks have been made for the realization of EBPHS in Shanghai. Afterwards, targeted studies on explicit technical problems have also been performed based on cause-analysis. As a result, references could be provided to carry out new policies and measures for sustainable development of the community public health service health in Shanghai.The objectives are explicitly given as follows:1. Studying the external conditions for realization of the EBPHS in Shanghai from different perspectives2. Comprehensively analyzing the funding and staffing situation related with the realization of EPBHS in the sample community3. Finding out the basic reasons that determine the supply of EBPHS grounding on sorting the influencing factors4. Solving the bottleneck technical problems in the realization of the EBPHS5. Making recommendations on current policies to fulfill the EBPHS in Shanghai[Methodology]Considering the context of the CBPHS, we adopted the policy cycle theory from World Bank Research Center as the guiding theoretical framework. On the basis of "structure-process-result" analysis method, we discussed mainly from the view of "resource allocation" on the premise that external environment, resource input, process, output services and other aspects have clear links. Data sourcesWe have done systematically studies on the collected materials on EBPHS, definition of CBPHS, cost accounting, human resources and the construction of service-oriented government, which consist of electronic database, national and Shanghai(including municipal and sample counties) policy documents, the internal research reports and almanac data.In addition, we have randomly selected24community health service institutions spread in5districts of Shanghai as sample cases. These5districts are Luwan District and Zhabei District (city center), Jiading and Minhang Districts (outer suburban), Chongming County (suburbs).Using the designed questionnaire, information has been systematically collected, which includes financial revenue and expenditure, population, geography, community public health funding, community health manpower, current services situations and so on. Furthermore, interviews have been made with the experts who are from Shanghai Municipal Health Bureau, CDC, Health Bureau in the sampled counties, the community health management centers and the sampled community health service center.Analysis MethodsFollowing methods were adopted in the research when dealing with the specific materials:1. Literature inductive method:Inductive analysis was performed on the collecting literature, policy documents and internal research reports.2. Descriptive statistical analysis:Using descriptive statistics analysis the current situation and variation tendency of social economy, population health, health funds in Shanghai have been studied as well as the basic situation analysis of the sampled institutes. Based on this, research variables correlation is analyzed through the Spearman analysis. Efficiency study of the community health institutions in Shanghai was given by conducting data envelopment analysis (DEA).3. Health system diagnosis tree analysis:Basic reasons that influence the equalization of CPHS in Shanghai have been widely analyzed using this method, which is good at reason-retrospection and continuous causality-description.4. Qualitative and quantitative multiple arguments have been applied to the definition of the preferential service package and policy recommendations to the equalization of the BPHS in Shanghai.5. Cost accounting analysis:Based on the time allocation coefficient method, the standard cost of community PHS has been accounted by doing standard equalization research on the services income, humanpower and time consumption per unit service and other indicators in CPHS.6. Specification for gap analysis:Strategies and recommendations are put forward to narrow the gap which is from the analyzed funding and manpower resources allocation difference between reality and the ideal amount needed to fulfill the "equalization standards".Analysis tools:Arranging data through establishing Excel2010database; Accounting costs and processing descriptive data using Excel2010; Doing statistical analysis on data using database build in SPSS11.5; Doing envelopment analysis on data uses DEAP software.[Results]The results of this study contain the following aspects:1. Research thought based on the background of "equalization" has been elucidated in this study. It also elaborated the era background of EBPHS through the analysis of concepts about equalization as well as the current administration reform trend. It clarified that policy research context of the basic public health has changed. For the new goal of equalization, firstly, we have to analyze the internal and external environment of EBPHS comprehensively, then make clear the key problems and identify the "equalization standard" of BPHS, lastly, we should find how to allocate the health resource and adjust the policy.2. A detailed analysis of the environment, which the goal of EBPHS concerned, has been conducted. Listed below are the main results:Annually, Shanghai resident population growth rate is about3.65%, at the same time, floating population increase in the proportion of total population, in the year 2010is38.67%, apparently, these population problems challenged the capacity of community public health services. Easily, non-equalization could be proved through the differences of maternal mortality rate, infant mortality, incidence of infectious diseases report rate and death causes between the household and non-registered population. Widening gap of per capita disposable income and consumption level, between urban and rural residents, will increase the difficulty in realizing EBPHS.2006-2010, Shanghai municipal and county-level finance income’ growth rate is above15%annually, so the government have the ability to provide financial support for CHS. However, per capita funding of these districts is different so much that we could find the inputs are not equal at all. The level of community health funding per capita and community public health funding per capita is determined subjectively, this situation would be bad for the realization of EBPHS.Community health organizations have served the residents well with much more service output year after year. However, manpower shortage of CPHS is a universal and serious problem. Bad structure and insufficient manpower coexist in the peoblem.lack of uniform guidelines on service quality has a direct impact on service equalization, which cause only9.27%public health projects carried out in all24community health institutions samples.3. This study analyzes the effect factors of equalization systematically. Using diagnosis tree of health sector, we found that there was less mechanism design for the equalization in previous community public health policies, some basic problems in the kind of "financing" and "regulation" haven’t been settled well. The analysis believes that there were three basic technical difficulties:the target projects of equalization are not clear; the lack of cost accounting data support; the manpower shortage situation isn’t quantified.4. This Study has addressed several elementary problems that affect the realization of EBPHS in Shanghai city:Our research defined70specific services, formed a community public health services priority packet with Shanghai characteristics. These service projects have better foundation to be implemented, conform to the national policy guidance and play an important role in maintaining the health of the residents. It would lay solid foudation for EBPHS if we ensure services in this priority packet will provide equally.In this study, we clarified the way of accounting the CPHS cost and dealing with the key variables; calculation results from empirical data show that the current CPHS investing level of40yuan per capita is very insufficient, can not meet the needs of CPHS; standard cost per unit of a service could be taken as a reference price to buy the service; the priority-project total cost based on standard service amount would be a funding standard to support the CPHS; through the analysis, I would like to point out that if the funds need accounted for local fiscal expenditure proportion has exceeded some level, it should be paid by the municipal finance.In order to improve the CPHS efficiency, we need to build internal market for CPHS, and change the traditional approach of compensating the medical institutions, instead of purchasing services due to performance. Through literature review and the analysis of existing funding mode, this reaearch suggested the framework of service purchased, which provided a reference for the formulation of relevant policies.The humanpower needed for the priority services has been calculated in this study, the result showed that11sammples in all the24community health services insititutions suffered humanpower shortage. Based on the result, we had good reasons to believe that it is necessary to increase the manpower allocation criteria of CPHS in Shanghai, and advised that the new standard of humanpower allocation should be3persons/ten-thousand for center city,3.5persons/ten-thousand for suburban districts,4persons/ten-thousand for outer suburbs respectively.[Suggestion]According to the current situation of CPHS in Shanghai, systematical revolutions should be taken in the view of equalization of CPHS. Follows are the aspects we should pay attention to when making policies:1. Municipal departments must play the co-ordination role. From the results of the cause-analysis, we find that it is very difficult to realize ECPHS only relying on the county-level work and higher level administration should be involved for public health resources allocations. Shanghai municipal public health administrative department should seize the current opportunity to do research on the systems and ask for more support through the relevant policies.2. Scientific setting and strict implementing of the basic public health items in communities are vital to the achievement of the equalization. The first thing to apply this rule efficiently is enlarge the information sources, which might be from scientific development of the community diagnosis work, the setting up of health record database and the establishment of communities (residents) involved mechanism; Secondly, the service items should be adjusted dynamically and timely to make sure that provided services be consistent with the services ability. Finally, once the CPHS items and service standards are established, it should be examined rigorously to ensure uniform executions among all counties in Shanghai.3. The quality of operational system determines whether the CPHS resource could be allocated scientifically. Recommendations are given as follows:Human resource should be organized to formulate a unified, easily-operated standard of CBPHS. Standardization of services, which guarantee the quality, quantity and effects of services, is the basis to make service assessment index. Such work plays fundamental role in the realization of CBPHS equalization.Establishment of CBPHS cost sampling and systematization of the cost accounting should be accomplished. Cost accounting is not only a basic problem but one of the difficulties in ECBPHS. Accurate cost accounting based on the collection and analysis of cost data precisely and timely. We proposed systematization of cost accounting should be accomplished in Shanghai by establishing CBPHS cost sampling mechanism and setting up specific agencies to carry out CBPHS cost accounting.Municipal finance investment should be strengthened and connection between CBPHS funding and public expenditure should be established on the basis of cost accounting. The counties can set0.3%(not including depreciation maintenance) or0.35%(including depreciation maintenance) of its own fiscal expenditure as the upper limit of its total spending on CPHS, the difference between which and required city’s per capita input level should be made up by the municipal finance.We should attach great importance to innovative financing mechanisms, aiming to improve the efficiency of funds usage. Research suggests that service quality and quantity supplied could be guaranteed by promoting service supplier’s incentive using performance payment in the framework of service-purchasing mechanism. In this framework, funds gross is controlled by prepayment according the number of people, through connection between funds and services via establishing project budget system.Implementing leadership-responsibility system actively at all levels, strengthening the CBPHS evaluation was important to realize the ECBPHS. We must strengthen the ECBPHS and link evaluation results with staff rewards or punishments. Attention should be paid to the analysis and usage of the evaluation results, so the "rewarding good and punishing bad" measure could take its effect. Apart from that, decision making strategies and management systems in CBPHS could be strengthened by addressing and solving the problems during evaluations gradually.Great emphasis should be placed on reforming labor distribution system so as to improve the payment of CBPHS staff. The data analysis indicates that the expected payment is double of their current income. Besides regional factors, low payment and large work pressure make it hard to keep or recruit people in CBPHS, which will affect the services a lot. Our research suggested that payment system should also reflect the service-purchasing concept, so that service performance and payment could be linked once the price and requirement of the one service unit are specified. In this way,"working more and getting more" could be carried out by combining a fixed wage and floating salary.The number of CBPHS personnel could be increased while strict accessing standards should be obeyed. Because the humanpower is not enough to provide CBPHS needed by the equalization goal at present, we suggested that reformation of personnel system should be taken to make sure that staff number can be adaptive to the change of the CBPHS items. And all people involved could not go to work until getting the certificate with lots of strictly training.We should work from different directions to make the CPHS manpower strengthened. The situation in suburbs with poor economics is very serious, which can be improved by increasing the payments or staffing, strengthening staff internal flow, attracting more college graduates in the short term. Over the long range, the human development planning of CPH in Shanghai should be well developed from the students training to personnel assignment, then to personnel system reformation.It was necessary to establish the participation mechanism of the residents, which would promote the healthy development of CPHS. At first, residents could play roles in the service performance evaluation by "service record card" and telephone visiting. Then, residents could participate in the purchasing of services by using "service coupon" for some private services. At last, residents can involve in the self-managing of the community health problems by establishing "health management team", thus they can take more important parts in the definition of the service packet, evaluation of the performance and the supervision of funds usage.4. Take advantage of the information technology to promote the realization of ECBPHS. From the perspective of the current situation, it is of actual necessarity to set up databases and integrate the whole system, which should include electronic health information documents for Shanghai residents, health service information sharing, and health service cost data collecting. In order to make the isolated data from different counties integrated efficiently, the municipal administrative department of health should take leadership during the whole information system building process.