| Part 1 Research Background and significanceThe rural health service plays an crucial role in improving the whole national health quality, protecting rural productive force, revitalizing the rural economy and maintaining the social development and national stability. Since the foundation of the People's Republic of China, the government departments have been greatly developing health services, establishing a broadly basic health organization and shaping a set of three-stage (country,township,village) public health net and rural health service teams which aim at the prevention, medical treatment and health care. The health level and life expectancy of rural dwellers have been improved greatly and continuously, and the incidence rate of infectious diseases, rural infant mortality and rural pregnant and puerpera mortality have declined markedly. However, the shortage of finance, the lack of health personnel and inferior infrastructure severely hampered the development of the rural pubic health system. With the speeding up of social aging process and the improving living standards, the comprehensive influence derived from environmental, psychological and social changes and chronic diseases has exerted a continually significant consequence in the health situation of rural dwellers and the medical economic burden has increased continuously, resulting in severe poverty of rural dwellers for illnesses.At present, the main deficiencies existing in rural health services in China are as follows: (1) Insufficient funding of rural health services: the lack of government health funding resulted in not only the severe insufficiency of nationally rural health resources but also the continuous heavy burden of rural dwellers. (2) The shortage of professional and technical personnel for the rural sanitation and the maladjustment of rural health prevention and protection team with the need of health services: the rural health personnel resources are deficient, because the total number and technical capacities of personnel were low and the geographical distribution was uneven. Moreover, the elderly personnel working for health prevention and protection have relatively low technical capacity and lack professional training. (3) The weakening function of public health in townships hospitals: townships hospitals are the primary organization of rural public health work, the key point of the rural public health services system, and also an extraordinarily weak domain. On the one hand, the prevention and protection agencies are incomplete and the distribution of professional personnel are unequal. On the other, the fund appropriation for prevention and protection is so trivial that the public health services have enormous difficulty to carry out effectively and efficiently, bringing about the low function of prevention and protection services net throughout the rural areas. Moreover, driven by the locally economic benefits, the scope and standards of compensable health prevention and protection have varied and increased the burden of rural dwellers. (4) The poor accessibly and equity of rural health services: firstly, the medical sanitation institutions were deficient in remote areas. Secondly, the lack of governmental fund appropriation and benefits driven by the market economic conditions tremendously damaged the commonweal of public medical institutions. Finally, because of poor health awareness, rural dwellers failed to go to regular hospitals for examination and treatment when they are diseased. (5) The main problem of new rural cooperative medical systems: although these new rural cooperative medical systems have had relatively favorable achievements, the shortcomings were obvious. One is the cooperative medical fund had a relatively low standard and enormous difficulties to finance, and the other is the lack of the criterion of practical manipulation. The new rural cooperative medical system hardly sustain the disease burden of the sick rural dwellers, because of the limited percentage of reimbursement of medical expenses, they always abandoned the medical treatments.Nowadays, the research priorities of health services overseas in rural and remote areas are as follows: (1) The cultivation, supplementation and stability of personnel resources for public health in rural and remote areas: facing the reality that the health system has unstable health team and lacks sufficient technical personnel, a great number of nations choose primary and effective methods as follows: firstly, they pay enormous attention to training the technical capacity of rural community doctors to improve their services. Secondly, they also could run medical colleges to cultivate professionals for rural areas or recruit rural-oriented medical students. Finally, they enroll those staffs who have experience in rural health services to receive training again in professional schools. (2) The utilization of health services in rural communities: the international experts find, when they investigate the relatively low utilization rate of health services in rural communities, that rural patients choose health services institutions depending on their subjective feel and judgments. Meanwhile, the situation about the equipment level, the operation condition, service capacity and scope would influence the medical preference of rural patients, especially those elderly patients. They also state that strengthening the construction and the cooperation of the network of rural health services between rural community hospitals and large medical centers is an extremely significant access to meet rural residents' demands for health services.In China, there are many many studies about rural health service system, requirement and utilization of rural health service, rural health service professional team, rural public health service status, new type rural cooperative medical sysems, prevention and cure of rural areas infectious disease and chronic disease, service function orientation of township hospitals, health service status of village clinic. But, after the disease spectrum changed, and chronic disease had become the mostly health threaten, we lack of compositive and systemic study about health status with sanitation resource scheme. Our nation is still a huge agricultural one, whose rural dwellers accounts for 55% of the entire population, thus the health situation of rural residents is the biggest bread-and-butter issue. How to improve the public health services and basic medical services in rural areas and how to implement the primary health care for all the citizens, are the goal chased by all levels of government departments and health professional personnel. Ministry of Health has conducted three National Health Service survey, exerting an enormously positive influence in promoting national health reform and development, instituting the development plans for health enterprise, distributing health resources rationally, adjusting the supply and demand relationship of health services, and improving the health level of residents. However, China owning an extraordinarily vast territory, the economic development is unbalanced, the distribution of health resources is uneven, the people's level of education, living standards and health situations are extremely disparate. Therefore, investigating the situation about local residents' health and health services could help direct realistically how to institute development plans for local sanitary enterprise. Liuyang City is country-level city located in mountains of eastern Hunan Province, which was once an old revolutionary base. Although having active private economic and relatively fast economic development, Liuyang City has highlighted imbalances in development, which is to a certain degree representative in Hunan Province. From December 2006 to May 2007, we investigated the health condition, disease and economic burden and the utilization of health services of rural residents in Liuyang City. Then we generally studied medical institutions of all the townships to provide scientific evidences for instituting rural health policies that are applicable to social and economical development, further perfecting and promoting rural public health policies and works. Part 2 The health survey of rural residents in Liuyang cityObjective: To explore chronic disease spectrum and economic burden of the rural residents, and understand the current situation about the two-week prevalence rate and the utilization of health services in rural areas , and understand the prevalence rate of gynecological tumor in rural areas and explore the common risk factors , and understand reproductive tract infections status of rural women and the main influential factors, in Liuyang City, Hunan Province.Methods: (1)To determining the study objects using stratified cluster sampling ,they are Zhentou and Shankou and Yanghua villages and towns . we screened out the chronic diseases and selected a certain number of cases from 10 kinds of primary diseased randomly. Then we investigated their financial burden deeply, using methods that combined the questionnaire survey and medical inspection. (2)Using cross-sectional study, we surveyed the situation of injuring of past two weeks and of patients' searching for health services among more than 3200 rural residents in 3 villages distributed in 3 townships respectively, which involved Sankou, Yanghua and Zhentou. The content of the study involved social demography characters of family members, the severity of illness during the two weeks before the investigation, the situation about searching for health services, the options and reasons of choosing medical institutions and the reasons of failing to search. (3)Adopting the case-control study method, we investigated the menstrual history, marriage history, past history, family history of both 73 rural women cases acquired from communities and 140 control cases. After collecting the entire data, we made single-factor analysis and multivariate analysis. (4)As far as the general demography data, personal health habits, the utilization of the sanitary services and routine gynecological examination are concerned, we investigated some married women of childbearing age in 6 villages of 3 townships involving Zhentou, Sankou and Yanghua in Liuyang city using the systematic cluster sampling.Results: (1)The chronic diseases prevalence rate of rural residents in Liuyang City reached 160.62‰. The top 10 chronic diseases involved hypertension, calculus in urinary system, rheumatoid arthritis, chronic bronchitis, chronic gastroenteritis, coronary heart disease, intervertebral disc disease, cerebrovascular disease, diabetes mellitus, cholecystitis and cholelithiasis. Among all these illnesses, the prevalence rates of hypertension, rheumatoid arthritis, chronic obstructive pulmonary disease, coronary heart disease, intervertebral disc disease, cerebrovascular disease, diabetes, cholecystitis and cholelithiasis in Liuyang City were higher than the average levels in rural areas throughout the nation in 2003. The economic burden situation of 10 main chronic diseases is as follows: the economic burden of hypertension in the highest, reaching 71.8071 million yuan, followed by calculus in urinary system (51.2963 million yuan), intervertebral disc disease (31.9046 million yuan), cerebrovascular disease (31,440,600 yuan ), chronic bronchitis (30.4576 million yuan), rheumatoid arthritis (29.332 million yuan), cholecystitis cholelithiasis (28.2804 million yuan), diabetes (27.9456 million yuan), coronary heart disease (27,418,800 yuan) and chronic gastroenteritis (22,878,700 yuan). The total economic burden of 10 kinds of chronic diseases discussed above in 2006 reached 353 million yuan, in other words, 296 yuan per capita, accounting for 6.4 percent of Liuyang expenditure per farmer who had consumed 4614 yuan in 2006. Each patient suffered from an average of 2,800 yuan as economic burden, which accounted for 60.7% consumption expenditure per capita, 4614 yuan. (2)The prevalence rate of two-week rural residents in Liuyang City was 152.3%, which was slightly higher than 139.5%, the two-week prevalence rate reported by the national health survey in 2003. Among all the illness investigated, the chronic diseases, which continued for two weeks accounted for 74.8%, About 51.6% patients would choose to search for treatments and 64.4% of them would go to the second-stage health institutions, such as township hospitals and village clinics. The main reasons that rural patients failed to see doctors involved feeling their diseases slight by self-inductance, economic difficulty and non-effective measures, which accounted for 52.9%, 26.0% and 16.5% respectively. (3) The prevalence rate of gynecological tumor of rural women above 20-year-old was 4.7523 per thousand, among them the prevalence rate of malignant tumor was 1.6897 per thousand. The results of single factor analysis were as follows: the common gynecological tumor-related risk factors of rural women were dysmenorrheal, menopause, the use of postmenopausal hormone drugs, breast-feeding, contraceptive pill, gynecological inflammation, history of suffering from other chronic diseases and family history of cancer; the protective factor was pregnancy. The results of multivariate analysis showed that the common risk factors of gynecological tumor incidence of rural women were contraceptive use [OR=20.614, 95.0%CI (1.301 - 326.623) ] and gynecological inflammation [OR=31.635, 95.0%CI (1.836-544.966)] . (4) According to our investigation, 41.4% rural women in Liuyang city suffered reproductive tract infections, including chronic cervicitis and vaginitis, which were 68.3% and 31.1% respectively. The rural women who were 35 - 50-year-old had the highest reproductive tract infections rate 45.6%. The women who did occasional cleaning or non-cleaning had 1.59 times more risk in suffering the reproductive tract infections than those who did cleaning frequently and continually. Only 18.9% rural women wanted to go to hospital for treatment after they found they had reproductive tract infections symptoms.Conclusion: (1)In 2006, the prevalence rate of chronic diseases of rural residents in Liuyang City is higher than that of the national rural residents in 2003 and the chronic diseases spectrum was similar to that of national rural residents. The 10 kinds of major chronic diseases exerted an extraordinarily significant and financial influence on the patients in rural areas in Liuyang City. (2) The chronic diseases took an extremely crucial role in threatening the health of the rural residents; the distance was the primary influential factor in choosing medical institutions; rural patients always abandon the treatment for several reasons, such as little consciousness of maintaining health, the economic burden of seeing doctors and the financial difficulties of curing chronic illnesses. (3) Suffering from gynecological inflammation were common risk factors of gynecological tumor. (4) The reproductive tract infections rate in Liuyang City was closed to the results of other domestic relevant surveys; the major and high-risk population to prevent reproductive tract infections was 35-50-year-old married women in rural areas; lacking personal health knowledge and positive sexual health habits played an exceedingly vital role in reproductive tract infections of rural women; the utilization rate of health services was low after the rural women suffered reproductive tract infections; the census and treatment policies conducted by Liuyang MCH hospital in the past ten years were still crucial and effective to improve the health status of reproductive tract infections of rural women. Part 3 The survey of current status of rural health services of Township Hospitals and Village Clinics in Liuyang CityObjective: To investigate the present situations of sanitation resources and health service of township hospitals and Village Clinics in Liuyang City and to provide evidences for development of township hospitals and Village Clinics; To explore the current status about the child immunization and to provide evidences for evaluating the rural public health in rural areas of Liuyang.Methods: The study was conducted by a general investigation to 36 township hospitals and 687 village clinics, concerning the infrastructure, health professionals, primary care, public health service and income / expenses. We surveyed the situation about the basic and strengthening immunization among 630 children, who were born between January 1, 2003 to December 31, 2005 in 3 townships involved Zhentou, Sankou and Yanghua. Then we made qualitative investigations about the professional training of planned immunization, vaccination management and data archiving.Results: (1) The average coverage of these medical institutions was 36,790 persons, which means 1.5 professionals per thousand residents; the professionals working in the medical institutions of countries and townships accounted for 88% of the total staffs; the average person of public health personnel was 3.8 persons per hospital. In 2005 the sickbed utilization mean ratio was 58.9% and 184,639 patients received diagnosis and treatments per year. 2/3 income of township hospitals derived from vaccination in the recent five years. The maximum of personnel, sickbeds, operation areas and capital asserts were 196 person, 170 person, 10900 m~2 and 21.46 million yuan respectively. Oppositely the minimum of them were 7 person, 6 person, 400m~2 and 0.41 million yuan. (2) According to the investigation, there were 1,158 health professionals and 757 village doctors totally, which meant 0.89 health personnel and 0.58 village doctors were working for thousand residents. The village doctors who were over fifty years old accounted for 52.3%, and who lacked professional training accounted for 54.8%. The operation areas of village hospitals varied from 200m~2 to 1m~2, and 36.7% of them were lower than 45m~2. The capital asserts fluctuated from 1.5 million yuan to 10 thousand yuan. 76.8% of the entire income of village clinics rooted in the sales amount of medicines. The main public health services of village clinics included reporting epidemic situation, health education, informing vaccination and reporting birth and death and so on. (3) Three villages had 5 professionals serving rural dwellers according to the planned immunization program of a total population of 98,383 residents and the professionals ratio was 51 personnel per million citizens; among 3 age groups the average ratio of running the cards and certifications was 90.5% and 86.7% respectively. 75.06% of children in 3 age groups had full basic immunization, which involved Bacilli Calmette Guerin (BCG) vaccination 91.52%, Oral Polio Vaccine (OPV) 86.49%, Diphtheria Pertussis Tetanus (DPT) 83.91%, Measles Vaccines (MV) 81.08%. The rate that children accepted all the four vaccination was 79.35% in 2003, 76.74% in 2004 and 69.53% in 2005; the hepatitis B vaccination coverage rate was 84.3% and the coverage rate of strengthening immunization of DTP and MV were 48.6% and 50.2% among children all the three age groups; the running rate of card and certification of the floating population and the children who were born against one-child policy were only 57.4% and 74.4% and the four vaccination rate and hepatitis B vaccination rate of them were 42.6% and 48.9% respectively. Conclusions: (1)The health resources of township hospitals are relative enough in Liuyang City; The developing trend of Liuyang township hospitals reveals polarization, which has affected the fairness and the availability of countryside primary care and public health service; The government investment is relative insufficient, which weakens the capability of public health service of township hospitals. (2)The obviously bipolar trend of medical hospitals in villages in Liuyang City would influence the equity and accessibility of rural basic diagnosis and treatments and public health services; The main function of village clinics were simply, mainly depending on the sales of medicine. The health personnel were elderly and lacked professional training. (3) In three townships investigated, the four vaccination rate showed a downward trend year by year, while strengthening vaccination rate was low in general; the townships workstations had a relative shortage of professionals, which led to the fact that the vaccination coverage radius was so large that the vaccinations of children in remote areas were not protected by the immune effects of the township planned immunization; the floating population and the children born against one-child policy were the weak points of the plan; the four vaccination rate was relevant to four factors, such as the professionals engaging in the vaccination enterprise, year of birth, place of birth and having vaccination card. Part 4 The comprehensive analysis of rural health services investigation in Liuyang1) Situation and challenges faced: (1)Chronic diseases had become the most essential factor threatening rural residents' health status. So heaviest burden was the economic burden after the rural patients suffered chronic diseases, and new rural cooperative institutions hardly help rural dwellers resist the risk of diseases. the utilization of health services was significantly restrained. (2) township hospitals are the main healthcare institution that rural residents utilize health service, the insufficient funding appropriation of rural health resulted in continuously tremendously bipolar trend between the formation and development of health institutions in countries and that in villages. Meanwhile, the weakness of rural public health services would significantly influence the public welfare of rural health institutions and the equity and accessibility of rural basic medical services and public health services.(3) The reproductive tract infections rate of married women in reproductive age and the incidence rate of both benign and malignant cancer of rural women are more important problem in Liuyang City. The health knowledge and behaviors were the main influential factors and the reproductive tract inflammation was the significant risk factor. But the utilization rate of health services of rural women's gynecopathy in Liuyang City was so low that the health prevention and protection of rural women suffered tremendous pressure. (4) The formation of professional team in rural sanitary organizations in Liuyang City failed to be reasonable. The staffs for medical treatments were sufficient, but the personnel working for public health and nursing care, who had higher commonweal and lower economic benefits, were relatively deficient to meet the standards of rural health services.2) Policies recommended: (1) According to "rural health service system formation and development planning", we could institute the construction standards of medical institutions in countries and townships and standardize the establishment of rural sanitary organizations; we could increase the fund that government appropriated to the hospitals in rural and remote areas and decline the gap between the medical institutions in countries and that in villages; we could enlarge the supplement, training and evaluation of service personnel in village stations and ensure all the rural dwellers could share fairly basic medical treatments and public health services. (2)We could transform the mode of medical institutions in countries and townships to the style of community health services, and strengthen the public health services functions of medical institutions and clinical doctors in countries and villages. We could also enlarge the fund appropriation for public health services and the total number of professionals and increase the level of planned immunization, disease prevention and women and children health care, it can enhance the commonweal of rural health service. (3) The most primary responsibilities as the doctors in medical institutions of countries and townships was to control and govern the prevention and medial expenses of chronic diseases and to increase the health level of rural dwellers. (4) It is recommended that the insurance standards of new rural cooperative institutions should not be lower than that of townsmen,. Make sure the rural dwellers can receive beneficial treatments in time, which would help farmers resist the risk of serious illness. (5) We could increase focus on the cyclical health examinations of high-risk and crucial population to ensure early discovery, diagnosis, treatment and control. 3) Discuss of research achievement and deficiency: (1) Through the systematic survey of the main health problem of rural dwellers, the need assessment and the utilization of health services, the financial burden of diseases, the health resources allocation and situation of medical institutions in countries and townships, we could basically understand the current problem and pressure existing in the rural medical enterprise in Liuyang City, to provide a theoretical evidence for the rural health development plans and the establishment of the local health policies. However, the present investigation did not involve the quality of rural medical health services and the situations about rural mental health, which are the focus of further study. (2) On the basis of the comprehensive survey of public health services, the economic balance and the professionals, we surveyed the basic immunization coverage rate and its influential factors about rural children, to evaluate the development and implementation of the core work of public health services. Through the study, we found several deficiencies in the current rural public health services system and provided the theoretical references for the reasons of the deterioration of the rural public health care and the direction of further implements, but the evaluation of the implementation and effectiveness of the rural public health services needs more comprehensive indexes to be reflected correctly and precisely.
|
PDF Full Text Request