| [Purpose] Based on the theory on Ecological Niche,the purpose of this study was to investigate the ecological niches of the medical service capacity of the township hospitals in the rural health system from a systematic perspective.The influencing factors of the ecological niches of the township hospitals were also explored in the present study.Based on the findings in this study.Suggestions on the capacity building of the rural primary health facilities were proposed,which might contribute to the development of the hierarchical medical system.[Methods] Based on a multi-stage stratified unequal-probability sampling method,370 township hospitals in 6 provinces were selected as study subjects.Based on the theory on Ecological Niche and the literature review,the theory on the Ecological Niche of the township hospitals was developed to portray the relative capacity of township health centers compared to the county-level medical institutions in their health systems;Based on the theory on the Niche Situation,an indicator system for measuring the ecological niches of the medical service capacity of the township hospitals and a model of influencing factors of the niches were developed.The data were collected through the annual report system in the county health bureaus and the questionnaire for the primary care facilities.The ecological niches of the medical service capacity of the township hospitals in the rural health system in 2017 were calculated by the formula of niche calculation from the niche situation theory,and the degrees of niche overlap were calculated by the Pianka’s formula of the niche overlap calculation.Lowess fitting was used to explore the relationship between the ecological niches and the degrees of niche overlap.K-means cluster analysis were employed to classify the township hospitals with different niches.The influencing factors of the niches of township hospitals were selected through the literature review under the framework of the Ecological Niche Theory.Disordered multiple classification logistic regression were used to examined the direction and degree of the influence of the selected factors.[Results] Among the 370 township hospitals investigated in the present study,there were 105 central township hospitals.The difference between the investigated township hospitals and the county-level medical institutions existed in each province in terms of medical service volume,medical resources,financing and management.In terms of medical services volume,only the township-level institutions in Henan Province have more patient visits than the county-level institutions,and the hospitalization services in each province are mainly provided by the county-level institutions.As for the medical resources,the ratio of the resource of the township-level institution to those of the county-level institutions in Shandong Province was the lowest,with the value of 23.45%、27.58% and 10.74% in terms of health technicians,the number of beds,and the value of equipment costing more than 10,000 yuan.In the aspect of financing,more than 80% of the income of the county-level of each province derived from medical service provision,and this figure reached to 95% in Hubei Province.The income of the township hospitals mainly came from government subsidies.Significant differences of the medical service volume,medical resources,financing and management of the township hospitals among the provinces were found in this study(P<0.001).The average ecological niche of all township hospitals was 0.129,while the lowest one was 0.021,and the highest one was 0.366.Significant differences were found in the average ecological niche of the township hospitals among different provinces(P<0.001),and the value of Guangdong Province was the lowest,which is 0.089.The average overlap degree of township hospitals was 0.384,with a minimum of 0.099 and a maximum of 0.766.It was found in the results of the Lowess fitting of ecological niche and overlap degree of the township hospitals that the overlap degree presented a u-shaped curve that first decreased and then increased with the increase of ecological niche.All the township hospitals were divided into three categories by K-means cluster analysis,which were of high,medium and low ecological niche separately.The township hospitals that located on plain terrain,participating in medical alliance,applied telemedicine,and set up independent department of traditional Chinese medicine were more likely to have a higher ecological niche,while the whole-budget management had negative effect on the ecological niche(P<0.05).[Conclusion] On the whole,there is a large gap of the medical capacity between the county-level and township-level medical institutions,and the overall medical capacity of the township hospitals is low.The gap of the medical capacity of the township hospitals also exists among different regions in China,as well as the ecological niche of the township hospitals in different rural health system.In the health system,the overlap degree between the township health centers and the county-level institutions is higher when the township hospitals were in higher and lower ecological niche,indicating that the greater competition between the township-level and county-level township hospitals would result in the structural friction and lead to the decreased efficiency of the health system.The mode of revenue and expenditure management and the geographical location of township hospitals could affect their medical service capacity through stimulating the intrinsic motives of the township hospitals and competition between the county-level and township-level institutions.The appropriate competition could improve the ecological niche of medical service capacity.The vertical cooperation in the rural health system are important measures to reposition township hospitals in the system,such as the construction of medical alliance between the county-level and township-level institutions and the development of telemedicine,which could improve the ability of the less-satisfying township hospitals and optimize the cooperative relationship between the township hospitals with higher capacity and the county-level institutions.The development of traditional Chinese medicine departments could optimize the allocation of resources to balance the development between the traditional Chinese medicine and the western medicine departments,which would help to improve the ecological niche of township health hospitals in the system. |
