Research On The Health Resource And Service Integration Based On The Township And Village Health Integration Policy

[Objective]:This study analyzed the role of Township and Village Health Integration (TVHI) policy in health resources and services integration (HRSI) of rural China from both theoretical and empirical perspectives. First, the thought of HRSI was explored, and "resource and service", the two critical directions in the current development of health integration, were specified. And then, the main approaches and development of HRSI was analyzed in terms of the model evolution. After the conceptual framework of HRSI was constructed, the structural model of HRSI was established so as to explore the operational process and effect pathway of integration influencing factors. Moreover, the implementation effect of TVHI in the sample areas was evaluated by utilizing the indicators from the aspects of structure, process and outcome. Finally, the strategies and suggestion of further improving TVHI and promoting HRSI were concluded.[Methods]:With the purpose of assuring sample representativeness, hierarchical clustering and typical sampling method were performed, and four counties were selected from four provinces (Guangdong, Chongqing, Qinghai and Guizhou) nationwide. The survey units were the health service agencies and health bureau in the counties, and survey respondents were the health administrative staff, medical workers and rural patients. The health integration thought and its evolutionary progress in TVHI was analyzed through extensive literature review, and the conceptual framework of HRSI was generated by systematically analyzing its background, objectives, elements, strategies. Structural Equation Modeling (SEM)were utilized to explore the operational process and effect pathway of integration influencing factors. Difference in difference estimation was performed to evaluate the impact of TVHI on HRSI from the aspects of structures, process and outcomes. Survey materials were acquired via literature and field survey.[Results](1)According to the integrating subject, the health integration could be classified into resource integration and service integration. The former could be considered as a basis or means of achieving the later one, whereas the later one could be considered as the direction and goal of the former one, and the integration of resource and service is similar to the unification of means and goal.(2)The development of the TVHI’s connotation has gone through the process of "agency, organization, service", the process corresponded to the strengthening of integration, and that is to say, the emphasis of integration goes from the resource allocation to the service continuity.(3)HRSI contains two dimensions which are the structure of organizational resource and the pattern of service provision. The Structure of organizational resource refers to the integrated organizations’ internal and external resource elements and their relationships, and after that the continuity and coordination of service provision pattern were improved.(4)The structural model, including4latent variables and12observed variables, was constructed and the effect pathway was explored. The reliability of the questionnaire was relatively high (Cronbach’s a=0.884), the discriminant validity was not ideal(0.189-0.549), and the convergent validity was good though(0.452-0.819). The goodness-of-fit indexes for the model met the criteria (GFI=0.957, RMR=0.048, RMSEA=0.037).(5) The hypothesis that the positive changes of the HRSI variables will influence the effect of HRSI positively was verified by the SEM. According to the comparison of the path coefficients, governmental strategy had a stronger influence on the organizational management (standardized estimate=0.742, p-value<0.001) than it had on service pattern (standardized estimate=0.367, p-value=0.004); Organizational management (standardized estimate=0.457, p-value<0.001) and service pattern (standardized estimate=0.184, p-value=0.046) both had considerable influences on the effect of HRSI, and the influence of service pattern on the effect of HRSI was relatively low. (6)The sample areas were divided into compact integration pattern and loose integration pattern, and13indicators from the structure, process and outcome of TVHI was used to evaluate the integration effect of TVHI implementation. The TVHI group had better changes in all the indicators as compared to the non-TVHI group, and the differences were statistically significant. The compact integration pattern had stronger and more obvious effect than the loose one; however, it’s worth noting that compact pattern (DID estimate=-12.994, p-value<0.001) had lesser effect of lowering the rate of village clinic’s independent legal personality than loose pattern (DID estimate=-25.481, p-value=0.002) did, and no significant difference were found between loose pattern’s TVHI group and non-TVHI group about the patient cognitive evaluation of the service continuity.[Conclusion and Suggestions]:TVHI is the typical practice of HRSI in China. Through the measures of integrating organization, optimizing resource allocation, and combing service elements, etc., it did strengthen the rural health service system, improve the continuity, coordination and accessibility of rural health service and satisfy the diverse health demand of the rural residents.For better utilizing HRSI to direct the implementation of TVHI, and accelerate the transition of service pattern towards continuity and coordination, our study suggested the following strategies:(1)To adjust measures to local conditions, and construct the adequate pattern for rural health integration;(2)To modify the policy goals and implementing strategies of TVHI;(3)To mobilize factors of production, and accelerate the improving of mechanisms and strategies of HRSI;(4)To summarize the experience, and enhance the continuity of rural grass-root primary health care services.