| During the past 40 years since China’s reform and opening-up,the healthcare delivery system in China has achieved impressive progress,with a substantial expansion in the development of health facility,personnel,and infrastructure.A welldesigned healthcare delivery system covering urban and rural area,including hospital,primary healthcare institutions,and professional public health institutions,has been established.Despite the tremendous achievement,Chinese healthcare system faced a series of issues,such as insufficient quantity and low quality of healthcare resources,unreasonable structure and geographical distribution of healthcare resources,fragmented service system,unbalanced expansion in some public hospitals,and insufficient overall management and allocation.The insufficient healthcare resources and unreasonable healthcare resource distribution have undermined the equity and efficiency of health care delivery in China.The mismatch of healthcare delivery system and population’s healthcare needs have raised a considerable concern,called “Kan Bing Nan,Kan Bing Gui”,in the Chinese healthcare system.Specifically,“Kan Bing Nan”can be attributed to the mismatch of healthcare delivery system and population’s healthcare needs.China now has established a basic medical insurance system and faced a series of challenges such as aging,environmental issues,transition of disease spectrum,and changes of medical models,leading to a substantial increase of healthcare needs.As a key component of healthcare delivery system,sufficient healthcare resources and balanced healthcare resource distribution are the prerequisite to meet the needs of health care and promote population health.The need of health care is increasing but the healthcare resource availability is limited,so how to allocate the healthcare resources from a perspective of regional balanced development aiming at achieving an equal and efficient healthcare resource distribution becomes a big challenge for Chinese government.As the starting point of health equity,whether the regional healthcare resource distribution is balanced plays a critical role in the access to health care and eventually in the health equity.Aiming at depicting the healthcare resource distribution and promoting a reasonable distribution of healthcare resources via allocation optimization,we moved on to the following questions: first,what is the geographical distribution and temporal trend of healthcare resources at the county level in China? Does the healthcare resource distribution tend to be more balanced and lead to an improvement in the equality of healthcare resource distribution? Second,what are the potential factors that could explain the county-level disparity in the healthcare resource distribution? Third,will the expansion in healthcare resources and improvement in equality of healthcare resource distribution have the potential to improve the population’s health outcomes? What are the possible mechanisms? Finally,how can we optimize the distribution of healthcare resources with an aim of promoting the equity and efficiency? Will the optimized healthcare resource distribution have a potential to improve the population’s health outcomes? To our knowledge,no previous study has assessed the geographical distribution of healthcare resources and its associated factors,as well as the effect of changes in healthcare resource distribution on population’s health outcomes.To promote health equity,how to optimize the healthcare resource distribution based on equity and efficiency is a question with great practical significance.The results will inform the balanced distribution of healthcare resources and provide scientific support for health equity.To answer the above questions,we used the national social and economic data,population data,and geographic information data to construct a county-level panel data in China between 2000 and 2019.First,based on the county-level panel data between 2000 and 2019,this study adopted hospital beds as a proxy indicator to measure the healthcare resources at county level.We depicted the geographical distribution and temporal trend of healthcare resources,with a main focus on quantity,equality and clustering.We employed the traditional and spatial divergent regression model to assess the divergent process of county-level hospital beds,and decomposed the county-level hospital bed disparity using a multilevel regression model.We found that in spite of the impressive overall expansion of county-level hospital bed availability,large heterogeneity in the geographical distribution of and pace of expansion in hospital beds existed in China between 2000 and 2019.At a county scale,our findings revealed that eastern developed region,on average,has a higher level of hospital bed density(measured by the number of hospital bed per 1000 population and 1 square kilometer)and larger pace of hospital bed expansion than the other two regions,and western region was persistently disadvantaged in these two respects.Meanwhile,China has made noteworthy progress in the equalities in geographical distribution of hospital bed density across counties between 2000 and 2019.We found robust evidence for β-convergence of hospital bed density across counties both in the short term and long term,supporting the dynamic decline of inter-county inequalities of healthcare resources over time.Furthermore,county-level factors exerted the largest influence both on the cross-sectional variations in hospital bed density across counties,as well as the variations in hospital bed expansion between 2000 and 2019,suggesting that there would be great benefits from the policies or interventions aiming at closing the gaps of healthcare resource availability at a finer spatial scale rather than the regional or national level.Second,we used spatial panel regression model and Bayesian spatiotemporally varying coefficient(STVC)model to evaluate the factors associated with county-level hospital beds.We found that population size,hospital beds,economic characteristics have an evident positive spatial clustering,i.e.,a group of adjacent counties with similarly high and low healthcare resources,such as population density,the number of employees,gross domestic product(GDP)per capita,gross financial revenue and expenditure per capita.The spatial clustering became more evident over time.The health needs,insurance level,price of health care,and economic level were associated with county-level hospital beds.The number of employees,the number of primary school student,the proportion of elders,GDP per capita,gross financial revenue per capita,and savings per capita have a direct effect on the local development of hospital beds,and an indirect effect on the development of hospital beds in adjacent counties.Furthermore,the associations of population density,the number of employees,GDP per capita,and gross financial revenue per capita with county-level hospital bed availability were found to be different in the geographical and temporal dimensions.Third,we adopted life expectancy and maternal mortality ratio(MMR)to assess population health outcomes,and investigated the impact of hospital bed availability as well as the equality in hospital bed distribution on life expectancy and MMR among 31 provinces in China between 2000 and 2019.We also used a mediation analysis to examine whether the association of hospital beds availability as well as its equality at county level with MMR was mediated by the facility birth rate.We found that life expectancy increased from 71.24 in 2000 to 74.91 in 2010.Although the western provinces experienced higher increase in the life expectancy,gaps still remained compared with eastern and central provinces.Meanwhile,MMR has been reduced substantially between 2002 and 2019.Compared with highest income provinces,lowest income and lower middle income provinces experienced larger reduction in MMR.Paralleled with the decline in MMR has been the huge raise in hospital bed availability and improvement in equality of hospital bed distribution.Increased hospital bed availability as well as improved equality of hospital bed distribution were found to be significantly associated with reduced MMR,thus suggesting that the expansion of healthcare resource availability as well as the reduction in hospital bed distribution equalities have the potential to produce measurable population health improvements.Facility birth rate was found to play a mediating role in the association of hospital bed availability as well as hospital bed distribution inequalities with MMR.Finally,with the goal of equity and efficiency,we used location and allocation model to optimize the current county-level hospital bed distribution as well as the hospital bed distribution after increasing the overall quantity of hospital beds.We found a more balanced distribution of hospital beds at county level after the optimization of current hospital bed distribution with a goal of equity.The Gini coefficient was reduced significantly and average MMR also have experienced a reduction,indicating that the optimization of current hospital bed distribution with a goal of equity has the potential to promote the population health.In the scenario of increasing the quantity of hospital beds,compared with linear increase in the county-level hospital beds,optimization of hospital bed distribution with a goal of equity or equity and efficiency has a more balanced hospital bed distribution and an evident reduction in MMR.In those regions with declined hospital bed availability,improving the equality of hospital bed distribution could mitigate the increase of MMR attributed to the hospital bed reduction.Such evidence suggests the optimization of healthcare resource distribution have a potential to improve population health,and underscore a critical priority to achieve a balanced healthcare resource distribution across regions in order to achieve the penetration of universal healthcare coverage. |
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