Development Of Township Health Centers Under The New Health System Reform

The new health system reform set the overall goals of constructing a basic health care system covering urban and rural residents. Providing equal basic public health services and basic medical care services and strengthening the capacity of the primary health institutions is a core strategy to achieve the goals of the health system reform. Township health centers (THCs) are the backbone of the three tier rural health service network and the main force to provide essential health services to most of the rural residents. The improvement of the functions of THCs are very important to achieve the goals of health system reform and to ensure the rural residents to enjoy the essential health service.The current researches found that the funcions of THCs are weakend and medical services are more valued than public health services. The lack of a clear and detailed definition of the functions, inadequate government investment, unreasonable staffing, low level of the service capacity and the lack of effective supervision and assessment are the main factors that against the improvement of the functions of THCs. The following questions are needed to be solved:1) most of the researches of the functions of THCs are just discussions of different views, and the empirical researches only covered part of the functions, there are few of comprehensive and integrated evaluations;2) most of the researches are cross-sectional researches and there are few researches on dynamic changes;3) there are few comprehensive studies on the changes of financing, human resources, and functions of township health centers. The new health system reform introduced a series of policies for the primary health institutions. Functions, financing and human resources of THCs were covered by these policies. Under this environment, further researches are needed on what changes has happened of the financing and human resources and how these changes affect the funcions of THCs, whether the changes are appropriate with the goals of health system reform, and what problems still exist.The overall objective of this study is to analyse the changes of financing, human resources and functions of THCs under the new health system reform, and to propose strategies on the improvement of functions of THCs and achievement of goals of health system reform. The specific objectives of the study include:1) reveal the changes of financing and human resources of THCs before and after the new health system reform;2) analyse the changes of the functions of THCs before and after the new health system reform;3) explore the influencing factors of the functions of THCs;4) provide evidence and propose strategies to achive the goals of the new health system reform.Date and MethodsQuantitative and qualitative methods are adopted in this study. There are two data sources, two national surveys and a special survey. The institutional data of288THCs in31provinces are from two national surveys conducted in2008and2011. Using before and after study design, the national data is used to analyse1) the input and implementation of the new policies of the new health system reform;2) the changes of functions, financing and compensation, and the quantity and composition of health human resources of THCs. The special survey was conducted in Jilin, Shanxi, Shandong, Chongqing and Anhui in2011. Institutional data of30township health centers and personnel data of403health workers including doctors, nurses and prevention and health care workers were collected. The data of the special survey is used to do supplementary analysis of the quality, training and mobility of human resources.106key informants are interviewed including officers of local health bureaus, deans of THCs, doctors and prevention and health care workers. The qualitative data are used to do deep analysis of changes of financing,human resources and funcions before and after the new health system reform.The definition of THCs’ service functions is primarily based on the contents of essential health services in "the study of essential health service and national essential health service package in China", while making reference to other studies and the experience of the World Bank and other developing countries. The functions of the THCs were defined through discussing in the research team and consulting some experts. The functions of the THCs in this study consist of basic medical services and basic public health services, including9categories and100items. Two indicators, the proportion of items carried out and the proportion of institutions carrying out the items, are calculated to evaluate the implementation of services in THCs. In addition to educational level, closed-book exam is taken to test the basic health knowledge’s mastery of doctors, nurses and prevention and health care workers. The quantitative data were double entered into Microsoft Access, and then were analysed using Stata12.0. Qualitative data were analyzed using thematic analysis method.Main results(1) The implementation of health system reform policies and investment in primary health institutions The new health system reform, which includes a series of policies at the national level, focused on the functions, financing and staff team building of THCs. The new health system reform emphasize on strengthening the public health service functions in THCs, increasing the intensity of government investment and taking a variety of measures to strengthen the staff team building. Counties have promulgated specific policies, but the progress was different. The financial input in primary health institutions was gradually strengthened. In the western regions, fisical subsidies of primary health institutions mainly came from the central government. At first, counties focused on increasing the input into the infrastructures of primary health institutions, which peaked in2009and declined slightly in2010. In addition, the investment to primary public health services increased. Most of the counties linked up financial investment with performance. Most of the counties implemented essential drug policy, as well as the essential drug zero rate sales policy. The financial investment on training human resources for primary health institutions increased rapidly.(2)The changes of financing of THCs before and after health system reform After the new health system reform, the proportion of the sources of financing of THCs has changed. The proportion of THCs which implemented whole-budget management has increased by15.2percentage points. Compared to2007, the ratio of fisical subsidy income to total income increased in2010, which exceeded income from drugs and became the main source of income in THCs. But different regions had different situations. In2011in the western region there were57.5percent of THCs implemented whole-budget management; while in the eastern and middle regions budget management by remainder was the main financing method for THCs, and the percent of THCs which implemented whole-budget management was less than20%. In the eastern and middle regions, fisical subsidy income to total income ratio was still slightly lower than the income from drugs, while in the western region was higher than the income from drugs.The power of financial investment to THCs has increased, and the fiscal subsidies accounted for total expenditure has increased from20.4%in2007to34.9%in2010. According to the power of financial investment on personnel expenditures,48.9%of the fiscal investment was to subsidize basic personnel expenses, which accounted for59.1%of the personnel expenditures in2010; and the total fiscal subsidies to personnel expenditure ratio rose from0.62in2007to1.12in2010, which has been able to pay all of the personnel expenses. According to the power of financial investment on the infrastructure expenditures,63.4percent of THCs in2010did not get basic subsidies for the infrastructure, and67.3percent of THCs had no infrastructure expenditures in the same year. On the average, the basic infrastructure subsidies were greater than the expenditures in the same year. According to power of financial investment on the public health service expenditures, special subsidies of basic public health programs in2010accounted for27.8%of the fisical subsidies, and79.2%of the THCs whose basic public health project grants was above its basic public health project expenditures. According to power of financial investment on essential drugs zero sales policy, despite the number of THCs that implemented essential drugs zero sales policy greatly increased, only42.4%of the THCs actually received special fisical subsidies in2010, and the intensity of the subsidies was relatively low, accounting for only10.8%of the fiscal revenue of the THCs and could only afforded11.6%of drug expenditures.(3)Health human resources of THCs before and after health system reform In terms of the amount and composition of human resources, the amount of health technical personnel of THCs increased slightly, and the percentage which nurses accounting for also increased, but the invert of the ratio of doctors and nurses was still seriously. In terms of quality of human resources, health technical personnel’educational level grew though there were still58.3%of whom receiving secondary education level or lower; the score of exam on basic medical knowledge received by health technical personnel was not too high. The situation of personnel turnover has been eased to some extent. During2008to2010, the flow scale of THCs pesonnel was small with the average net inflow of each center rising from0.3person in2008to0.8person in2010. The average working time every day of THCs pesonnel was above8hours and the average working time every week was around6days. Most of health technical personnel thought themselves confronting heavy workload.The settings of the size of staffing changed differently in different regions, but the overall number of the size of staffing didn’t change obviously, which still couldn’t meet the demand of staff change and the amount of THCs which didn’t own enough size of staffing increased. Effects of inventions aiming for talent attracting such as special training and support from higher level hospitals were still not obvious.65.1%of health technical personnel in THCs has participated various types of training. In general, health workers thought that the quantity as well as the quality of training has been improved after the health system reform, however, their estimation to training opportunities were still at a low level.(4) Changes on service functions of THCs before and after health system reform:In general, service functions of THCs has been further improved. The amount of items carried out by THCs in2010was enhanced compared with that in2007, and the increase of basic public health service items was higher than that of basic medical service items. Basic public health service functions has received much attention, and THCs changed their functions from "valuing medical, despising prevention" to "paying equal attention to both basic medical service and basic public health service". Emphasis of the policy, the increase of the government investment and the implementation of assessment and incentive system were the main reasons which promoted basic public health service developing rapidly.In2010, the percentage of some service items accounted no more than90%. The main reason that these service items hasn’t been carried out was related with facilities and staff. The main reasons why basic public health service items didn’t carried out were "not required", followed with "limited capacity of personnel" and "lack of the amount of personnel". Some problems of THCs’service functions still existed. Some THCs which implemented essential medicine system and zero rate of medicine sale were not willing to provide medical service. Basic public health service function has been strengthened, however, due to the limited service capacity, some items facing difficulty in being carried out and the overall quality and level of service still need to be improved.Conclusion and policy implicationAfter the implementation of the new health system reform, policies in local regions were put into effect successively and the financial investment to primary health institutions was increased. Financing of THCs has changed, and proportion of THCs which implemented whole-budget management increased. Currently, fisical subsidies has become the main source of revenue while the percentage of medicine income has decreased. The power of payment of fisical subsidies to personnel expenditures and primary public health service expenditure were relatively high while fisical subsidies to the drug expenditures was relatively low.There were improvement in the quantity, composition and quality of personnel in THCs, however, the personnel quality was still at a low level. The quantity of training programs were increased and the quality of training was improved. The scale of personnel mobility of THCs was small and the attrition problem has been partly solved. However, the personnel mechanism is not flexible enough, for instance, the setting of size of staffing is still the obstacle of enrollment of the personnel. The effects of all the policy on attracting personnel were still not obvious.Both the functions of basic medical service and basic public health service have been enhanced in THCs, and the basic public health service functions developed more quickly,however, the quality still need to be improved. Human resource was the main factor influencing the improvement of the functions of THCs. The influence of variation of finance to primary public health care service was positive, however, it is opposite to the functions of basic medical service.The following policy suggestions are proposed:1) Related laws and regulations need to be formulated, and the responsibility of sustainability of government financial investment must be explicated;2) According to the request of primary health service, the quantity, composition and quality of the THCs human resources need to be reasonably planned;3) Loosen the setting of size of staffing and apply the flexible personnel mechanism; on the base of summary and evaluation of current policies and measures, the incentive measures to attract personnel to THCs should be taken to improve the quality of human resource t.4) The health care service quality should be given more attention to and detailed operation and guide book in the light of the request of primary health care service should be made up. Base on that, training program to the health care workers is to be conducted, meanwhile, put more rate on the service quality in assessment.