| BackgroundFacing the acceleration of the aging process and chronic diseases "blowout", as well as the increasing health service demand of residents, China confronts an enormous prevention and treatment pressure from chronic non-communicable diseases and aging. How to ameliorate unreasonable allocation of medical and health resources,and in the meanwhile, satisfy the residents’ medical and preventive care demands has been a big challenge for China’s medical and health reform.Community-based health service is a common way taken by most of medical and health service systems at home and abroad to deliver primary medical and health services, with the uniform target of attractting residents to utilize services in community health service center, which not only improve the convenience of residents, but also allocate the medical and health resources rationally. Family doctor is the gatekeeper of community health services, and the family doctor service is characterized withgeneral practitioner, community-sized, family-unit, and health management-targeted, all of the continuous, safe, effective and suitable, comprehensive medical and health management services are delivered in the form of service contract.Drawing on international experience, China decides to develop urban community health service and take the family doctor service pilot to tackle with the urging situation. Under a series of policies and regulations such as The Guidance on Development of Urban Community Health Services and Opinions on Deepening the Reform of Medical Health System,etc, the State Council developed community health service and trained general practitioners from1997. Premier Wen jiabao announced the establishment of China’s GP system on the executive meeting of the state council on June22,2011. On the basis of learning lessons from advanced foreign experience, some provinces and cities began to carry out the pilot combining their local situation and advantages. Under the promotion of new healthcare reform policies and the deepening of community service, Shanghai has carried out the family doctor service pilots since April2011. ObjectiveTo study the current situation of Shanghai pilot, and use World Bank’s results chain model to make a comprehensive assessment of shanghai pilot according to steps of "input-activity-output-outcomes-long-term outcomes", and to study the relationship among service demand, service deliver and service utilization, in order to assess the fulfillment of rights and obligations for both supplier and demander. At the same time, with learning lessons from home and abroad, we need to discover questions from current policy implementation and to put forward corresponding policy suggestions.MethodCombining with quantitative and qualitative research, the study makes an evaluation of Shanghai family doctor service pilot based on the framework of World Bank results chain model. Research methods include literature review, field survey, focus group discussion, comparative study, and typical case study, etc.Five pilot areas, including Xuhui, Changning, Zhabei, Pudong and Qingpu District, were selected as samples of random sampling. The samples of300staffs and600patients were invited to answer questionnaires about basic situation of community health service center, and the demand, supply? delivery and utilization of family doctor service. Epidata3.1and SPSS16.0were used to input and analyze data. Meanwhile, influencing factors of family doctor’willingness to replace work and residents’contract signing were analyzied with single factor chi-square analysis and logistic regression. Combinng with the results of "output" and "outcomes" in the result chain, the study made a comprehensive analysis of demand, delivery and utilization of family doctor service, in order to assess the fulfillment of rights and obligations from both sides of supplier and demander.Main resultsIt witnesses a big improvement of government investment and achievements in the aspects of finance, human resource and other resources.In the aspect of human resource, family doctors with rich community work experience mainly work in the form of GP team, and accompanied with high qualification nurses, physician assistants who received tranning or with service outsourcing. Low income-satisfaction and social-recognition contributed to family doctors’willingness to replace work which accounts for26.2%of the total family doctors. Income level is the most demanding factor to be improved while training opportunity is the least.In the aspects of financial, health care spending from local finance rose by0.1%in2011, and the part from district and county level witnesses a significant rose. The investment for community health service centers is mainly put into practice through specific funds, two lines of revenue and expenditure, and performance evaluation mechanism, but the subsidy varies in different areas.In the aspect of information, the foundation and implementation of residents’health information network improves the sharing efficiency of the medical and health resources, and facilitates family doctors to screen key population to take health management. Meanwhile, a variety of media and communication modes were used to expand the policy publicity.In the aspect of contract signing, up to30.1%of permanent residents have signed the contract, which will be promoted throughout the city in2013. The result shows that age and occupation are two main influencing factors for residents’contract signing. In the aspect of demanders’ service utilization there is a big improvement in the residents’recognition of family doctor service. Service ability and service attitude are still the most important influencing factors for residents’ siging choise.68.4%residents would like to take community health center as their first health diagnosing place, with a decline comparing with baseline survey. Restricting diagnosing freedom (39.85%), delaying treatment situation (36.09%) and leading to misdiagnosis (21.80%) ranks the first three reasons of that decline. Meanwhile, residents’self-evaluation of health and family monthly income influent the satisfaction of public health services. There is a serious lackness on liberalization of chronic diseases drugs use and service frequency. Complex service process mainly leads to the low percentage of referrals from high level hospital to community health center, which only accounts for8.3%of two-way referral service.Conclutions and suggestions1. With a big gap between the service demand, delivery and utilization of the medical and health resources, current services fail to meet the most urgent needs of supplier and demander. We should explore and satisfy the actual demand of both sides, and to realize the rational allocation of health resources.2. Under the current contract mechanism, there is lack of clear definition for rights and responsibilities, as well as a professional security practice environment for family doctors. A clear definition shoud be set and a security system should be ameliorated.3. Inadequate government spending still need to be improved and complex service process in the community health service center need to be simplified, so as to attract residents to utilize treatments in the community health service center as their primary option.4. The lack of doctor-patient trust relationship should be improved through the combination of government and social organizations, in order to achive the integration of policy value. |
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