Evaluation Of Performance Management Of Rural Township Health Centers And Its Implementation Effect

ObjectivesAs the linchpin of China’s rural three-tier health system, township health centers(THC) is the principle supplier of basic health services in rural areas. Since launching the new round of health system reform, governments at all levels nationwide have made continuous efforts in increasing financial support for THCs, whereas the service quality and efficiency of THCs have not been improved accordingly. Relevant policy has already been proposed in the new health reform that county-level health authorities should conduct performance assessment and performance management of primary health institutions in rural areas. And county health bureaus across the country have carried out various modes of THC performance management. Nevertheless, the performance management of rural THCs is still at its initial stage. A systematic theoretical framework has not come into being. Evidence has not been sufficient in supporting the effectiveness of performance management on quality improvement, efficiency upgrade and capacity strengthening of THCs. And there is no such research that has made comparative analyses of various performance management policies as well as their corresponding effects on the performance of THCs. Under such circumstances, this study was aimed to build a theoretical framework of performance management that could conform to the features of THCs in rural China, and then lay out the basic procedures and key sectors during its implementation. The framework would facilitate the transformation of performance management from theory into practice. Besides, this study was intended to employ panel data and strict policy evaluation methods to prove the effectiveness of performance management on improving service quality, enhancing service efficiency and strengthening service capacity. This research was also aimed to identify the major factors influencing the effects of performance management by conducting comparative analyses of different performance management policies and empirical analyses of their corresponding effects, which would provide evidence and reference for the government in making development strategies for the rural health system. Methods1. Study sample. Data were drawn from baseline and final surveys of China’s Rural Health Development Program, i.e. Health XI for short, and field investigations conducted by the research group. Data from Health XI included health surveys results and evaluation of THC clinic prescriptions from 40 project counties at 2008 and 2013, and annual health statistics reports of THCs in 5 project counties during 2011-2013. Data from field investigations included:(1) Interviews with key informants from 4 project counties of Health XI and relevant polices.(2) Survey results from 2 sample counties in Anhui Province. This study applied a prospective intervention design, included all 18 THCs in Jieshou County of Fuyang in Anhui Province into the intervention group, and all 31 THCs in Taihe County of the same city into the control group. The research group helped the health authority in Jieshou design the THC performance management policy, oversaw its implementation during the following year, and observed variation in effects on THC performance of different performance management policies. Self-designed questionnaires were employed to collect data in the two groups. Altogether evaluation results of 4900 clinic prescriptions and 2940 hospital records, basic knowledge tests results of 402 medical professionals, health literacy and satisfaction surveys results of 2680 rural residents, and satisfaction results of 670 THCs staff and 670 village doctors were collected. The research group also collected relevant policies and conducted face-to-face interviews with key informants using self-designed interview outlines.2. Analytical approach:(1) Literature review. Based on literature retrieved from major databases, case studies were made on the relevant research in other countries and cutting-edge theories that could be applied to THCs in China were identified. Current literature on domestic studies was also summarized. And a theoretical framework of performance management in line with the features of THCs in rural China was then constructed.(2) Differences-in-Differences(DID). Apart from the 2 counties in Anhui, another intervention-control group within the 40 project counties of Health XI was set. By using DID, variation in effects of different performance management polices on the services capacity of THCs was analyzed.(3) Data Envelopment Analysis(DEA). From perspectives of static and dynamic efficiency, the operating efficiency and its variation trend of THCs in Health XI project counties during 2011-2013 was analyzed by using DEA.(4) Cluster Analysis. The input and output indicators in DEA models were selected by Hierarchical Cluster Analysis.(5) Tobit Regressions. Major influencing factors of THC overall efficiency were identified by tobit regressions.(6) Composite Index Method. Based on a set of key performance indicators designed by the research group, this study calculated composite index for THCs and applied multiple linear regressions to explore major influencing factors of THC performance. Results1. A theoretical framework of performance management in line with the features of THCs in rural China was constructed. Four key sectors and critical issues were clarified.2. Policy analysis results showed that in the intervention group of Health XI, Gaolan County in Gansu Province implemented the most comprehensive policy of THC performance management, and the concept of continuous improvement was incorporated in all sectors of the policy. Kangle in Gansu, Gannan in Heilongjiang and Qianjiang in Chongqing Province also implemented systematic strategies to strengthen performance communication and performance improvement. Zezhou in Shanxi, Gaoyou in Jiangsu, Jiulongpo in Chongqing and Meixian in Shannxi Province still implemented performance assessment rather than the comprehensive performance management policy. Compared to the baseline level, average numbers of medications and average fees of clinic prescriptions in THCs of Health XI project counties declined, and the rationality of drug usage, maternal and child health care and health management of hypertension patients all improved markedly. The satisfaction rate of patients and residents also increased substantially. The variations in performance indicators due to the effect of THC performance management was statistically insignificant between the intervention group and the control group. But the differences between the baseline and final surveys were of statistical significance.3. Baseline and final surveys results demonstrated that THCs in Gaolan and Kangle made the most prominent progress in service quality and efficiency, and the satisfaction rate of patients and residents also increased significantly. DEA results revealed that in terms of THC operating efficiency, Kangle kept improving; Gaoyou declined at first but rose then; Meixian advanced in the first period and decreased in the second; and Zezhou was stuck in retrogression. Although Jiulongpo THCs ranked last in most performance indicators of the final survey, they achieved continuous progress in operational efficiency, which could be attributed to the implementation of the advanced internal performance management policy. Tobit regressions demonstrated that THCs were in shortage of registered nurses, while other health resources were sufficient in terms of quantity. Alongside the increase of staff and governmental subsidies, the overall efficiency of THCs declined, though.4. Through follow-up observation, the research group found that Jieshou Health Bureau did not implement the THC performance management policy. As a result, DID analyses showed that the differences in performance indicators between THCs in Jieshou and Taihe were insignificant. Among the indicators whose differences were of statistical significance, the correction rate of hospital records and the utilization rate of hospital beds presented a downward trend. And in 2014, the compost index of THCs in Jieshou was substantially lower than that of THCs in Taihe. In terms of internal performance management, the current assessment method was linking income of medical professionals to their service quantity, i.e. medical income determined personnel income. Regression analyses indicated that such income distribution mode had substantially negative effect on THC performance. ConclusionsBy comparing the policies and effects of THCs performance management in the project counties of Health XI and the two counties in Anhui, this study has proved that implementing standard performance management system could standardize the service behavior of THCs step by step, facilitate the rational supply of rural basic health services, enhance the service efficiency and strengthen the service capcity of THCs. On the contrary, if standard performance management has not been implemented, the service quality of THCs could decline significantly, and the quality of hospital services in particular. Furtherfore, this study has provided evidence that implementing performance improvement should be the focus of THC performance management. In terms of incentive mechanisms, the objective of performance management should be clarified at first, i.e. achieving performance improvement rather than implementing rewards or punishment. And a comprehensive incentive mechanism should be built which emphasizes both economic and noneconomic incentive strategies. Moreover, this study has demonstrated that applying systematic internal performance management mechanisms could also upgrade THC operating efficiency. In terms of human resources allocation, THCs have possessed sufficient staff. Therefore, simply recruiting medical professionals could not improve THC performance. The human resources structure should be optimized first and foremost. And then the training strategies of medical staff should be innovated in order to increase the ratio of licensed medical personnel, and registered nurses in particular.