Research Of Gatekeeper System In Community For Migrant Workers In Shenzhen City

Objective:This study aimed to understand the background, the mode and the status of the gatekeeper system in community for migrant workers in Shenzhen city, summarize the experiences, analyze the strengths, the weakness, the opportunity and the threats (SWOT), and explore the effects on the stakeholders. Besides, assessing the effect of this system on users, the evaluation and the view of users were also aims of this study. Finally, we explored the difficulties, the problems and the causes in the implementation process of the gatekeeper system, and then provided policy suggestions for the improvement and the generalization basing on the results.Methods:On the basis of reviewing literature and policy analysis, in-depth interviews and questionnaire survey were conducted to collect the data. We interviewed thirty-two stakeholders to collect the qualitative data, which were organizeed and analyzed by using the grounded theory and the Nvivos10analysis software. Then SWOT analytical method was used to analyze the strengths, the weakness, the opportunity and the threats, and stakeholder method was used to analyze the attitude, the standpoint and the cognition of the stakeholders.7,911users of community health service centers (CHCs) were effectively surveyed. Double entry of quantitative data was performed by Epidata3.0, and the data was analyzed by SAS9.2and SPSS18.0. Descriptive, comparative and logistic regression analysis methods were used to analyze the view and the satisfaction of the users.Results:1. Status and characteristic of the gatekeeper system in community for migrant workersIn2006, the gatekeeper system in community for migrant workers was established basing on the medical insurance system for migrant workers. The policy stipulated that all migrant workers insured in the medical insurance for migrant workers should firstly seek for medical service in CHCs medicare card bound to.In recent years, the number of insured migrant workers was growing, and in2011, the number reached4.86million, and increased1.78million compared to2006. The number and the rate of established CHCs showed an increasing trend. The general practitioners reached3,454in2011, and increased by1.79times compared to2007. The number of outpatients increased year by year, and reached32.30million in2011, accounting for36.39%of Shenzhen, far higher than the national level (19%). 2. Qualitative analysis of the gatekeeper system in community for migrant workers(1) Grounded theory based qualitative analysisThree core categories were separated out, and they were "the background","the experiences" and "the generalization" of the gatekeeper system in community, which included eight categories, and each category contained several sub-category and sub-sub-category. On this basis, the theory framework was built.The medicare for migrant workers followed the principle of "the low level, the wide coverage", and guaranteed the basic medical needs of the migrant workers. The CHCs covered about90%populations in Shenzhen, and within10to15minutes’ walking distance. The views on the quality of medical staff varied across different departments. The device allocation had not yet reached the requirements, and the drugs were lacked. The two-way referral criteria and program were clear, but the problem of "transfer up easily, transfer down difficultly" still existed. The software configuration of the information construction was not as optimistic as the hardware. The status of the insurance fund was stable.Finally, four grounded theories were preliminarily built:the establish of the gatekeeper system in community for migrant workers was inevitable, the operation of the system was relatively stable, but there still some problems hindering its sustainable development, and the generalization should be a step by step process..(2) SWOT analysisThe strengths of the system included providing standardized, continuous health services, establishing stable doctor-patient relationship, improving accessibility and equity, controlling costs, etc. The weaknesses included limiting right of choosing a doctor, reducing equity for inadequate competition, imperfect two-way referral system, etc. The opportunities that should be grasped were policy support, gradually improved CHC, insurance system support and so on. The threats that should be concerned about were poor service capability, not optimistic software configuration, and not yet changed concept of seeking medical service.(3) Stakeholder analysisThe stakeholders included doctors, patients, departments of medical insurance and government. For the government departments, establishing gatekeeper system in community could not only respond to the call of the country, but also solve the medical problem of migrant workers. For the medical insurance departments, establishing gatekeeper system in community could solve the insurance problem for migrant workers, and protect the safety of the fund. For employers and migrant workers, establishing gatekeeper system in community could not only alleviate the economic pressure to pay insurance costs, but also enjoy the medicare of outpatient and inpatient treatment. As for CHSs and hospitals, the number of the outpatients were guaranteed.3. View and satisfaction of users for the gatekeeper system in community Among the users, the female, the middle-aged and the elderly, and the low-income group were account for59.05%,0.37%and49.92%respectively.93.49%of the users (first contact users:94.68%, non-first contact users:92.25%) preferred CHSs when they were sick. Outpatient treatment cost was￥51.61, and the average drug cost of first contact users (￥32.28) was significantly higher than that of non-first contact users (￥24.04).73.47%of users (first contact users:74.16%, non-first contact users:69.71%) were willing to accept the gatekeeper system, and62.46%of the first contact users was willing to accept the system of medicare card binding CHSs. The users who had heard of the gatekeeper system, understood the policy, had confidence on the system, had referral experience, and had higher overall satisfaction were more willing to accept the gatekeeper system.Conclusions:The infrastructure and the service capacity of the CHSs have been improved, the two-way referral pattern has been formed. The gatekeeper system in community can meet the interest need of the stakeholder groups, has played a role in promoting health equity, and has value of generalization. However, the information construction is not optimistic, the referral system and the incentive mechanism are not perfect, the propaganda of the policy is insufficient. It was suggested that the government should play a leading role and increase investment,the supplementary policies and incentive mechanism should be improved, and the information system should be integrated and the view of resident for medical service should be changed. Besides, gradually promoting the gatekeeper system in community nationwide is feasible as long as there are policy support, system improvement and time cooperation.Innovation:1. In terms of the topic, this study closely gripped the key points of the health system reform, focused on the key issues such as hierarchical medical system and gatekeeper system to conduct empirical research. Thus, this was a leading edge subject.2. As to the content, it covered the various elements of the gatekeeper system in community, and the depth and the breadth of the content was leading in the country, which could provide a reference for the design of the national gatekeeper system in community.3. With respect to the methods, qualitative research methods, such as grounded theory, SWOT analysis, stakeholder analysis, etc, were used well, and we paid attention to the combined use of qualitative and quantitative methods to improve the reliability.