| BackgroundFamily doctors,also known as general practitioners,are "gatekeepers" of residents’health.They provide sound,effective,continuous,and appropriate health services and health management to each registered resident.In 2016,the Family Doctor Contracted Services(FDCS)scheme was officially initiated in China,which was aimed at optimizing health resources allocation and tackling with the issue of "difficult and expensive medical treatment".Family doctors play important roles in the construction of a hierarchical health-care system,deepening the reform of medical and health service providing,rational usage of health resources,and controlling medical expense escalation.Currently,a series of challenges has been emerged in the implementation of FDCS,since the scheme has been launched for a short time.The challenges are as follows:the registration rate is low,residents are not fully informed with the policy,and the quality of health services provided by family doctors is not in line with residents’ health demand.Additionally,the extent of FDCS implementation varies significantly across different regions around the country due to economic development divergence,especially in the remote rural areas.For example,rural areas have poor health infrastructure,weak information construction,lack of human resources,and low residents’ education and income levels.Therefore,the implementation of FDCS in rural areas faces more challenges.The health care issue in rural area has always been treated as a key task in the field of health in our country.At the same time,the rural basic health service system is responsible for maintaining the health of the residents in the vast counties,Shandong Province one of the largest agricultural provinces in China.The population of rural areas accounts for half of the total population of the province.Besides,the economic development level of the province varies across east,middle and west regions,which indicate a good representation of the whole country.Therefore,the study focusing on the practice of FDCS in rural areas of Shandong Province has great policy implications in improving health-care quality and facilitate FDCS in rural areas of our country.It should be noticed that the implementation of FDCS is comprehensive which subject to mixed effects of multiple factors,such as policy arrangement,incentive scheme,assessment and supervision by the government;the capability and institutional function of family doctor teams as well as health-care facilities;the cognition,attitude,motivation and cooperation of rural residents,etc.Theoretically,the Principal-Agent theory can establish the relationship among different factors and between the principal and the agent,and seek the optimal incentives.Therefore,we have applied the principal agent theory in the research framework to investigate FDCS policy implementation gaps and explore underlining reasons of the gaps from the perspective of agent relationships.According to the study background,we have proposed the research questions of this study as follows:What are the FDCS policy arrangements?How did FDCS implemented and What are the implementation gaps from the perspective of supply and demand side?How to tackle with policy implementation gap?Research purposesThis study will combine theoretical and empirical analysis method.Firstly,this study will systematically analyze the arrangements of FDCS in rural Shandong Province,and then explores the logic of policy implementation by investigating resource allocation mechanism,supervision and evaluation mechanism,financing mechanism,and accountability mechanisms of FDCS.Finally,propose policy optimization recommendations of FDCS to policy makers.The specific purposes including:(1)Constructing a theoretical analysis framework for FDCS;(2)Systematically analyze policy arrangements and implementation of FDCS from both of the supply and demand sides,and explore the key affecting factors;(3)Investigate policy implementation gaps and reveal the causes of them by applying principal agent theory;(4)Propose policy optimization strategies of FDCS.Objects and MethodsThe quantitative and qualitative data were collected from the field survey study named "Shandong Rural Primary Medical Services" project which was conducted from May 7th to 24th in 2018.A total of 3 cities(Zibo,Liaocheng and Binzhou),and 6 counties(Yiyuan,Huantai,Chiping,Dong’e,Huimin and Wudi)were selected using stratified random sampling method as the study sites according to the geographic location,economic level,and FDCS implementation status.The objects of this study included two categories:institutions and individuals.The quantitative data were collected from 31 township health centers and 184 village clinics,271 family doctors and 2,979 rural residents using self-conducted surveys as follows:pharmaceutical provision,information system construction,institutional policy arrangement;capacity of family doctors,service provision,and job satisfaction of family doctors;residents’ health status,health behaviors,preference of family doctor,and health needs,etc.The key informative interviews were conducted by interviewing 160 persons selected from family doctors,rural residents,and government officials using purposive sampling method.The analysis process of this study was consisted of three parts.The first part adopted the literature analysis method to summarize the policy and institutional arrangements of FDCS by analyzing governmental policy documents and research papers with respective to Shandong province and the sampling sites.The second part was to describe and analyze the implementation status of FDCS based on the data of supply and demand sides in the study sites;explored incentive mechanism and factors which affected job satisfaction of family doctors using statistical description and logistic regression analysis;Estimated residents’ preference for FDCS by applying discrete choice experiment method;Estimated factors which affected rural residents acceptance of FDCS by constructing a multi-level hierarchical model including individual and community factors.The third part was to investigate policy implementation gaps and reveal the underlying causes by analyzing qualitative data and using thematic framework analysis method.The qualitative data were analyzed with respect to principal agent relationships among government,family doctors,and the residents,and were summarized according to four thematic:resource allocation mechanism,funding and payment mechanism,evaluation and assessment mechanism,and the accountability mechanism of FDCS.Finally,this paper comprehensively analyzes the framework of FDCS and the deviation of policy implementation,and proposes strategic suggestions FDCS optimization.The data were analyzed using SPSS 22.0 and Stata 14.2 for descriptive statistical analysis,single factor and multiple factor analysis,hierarchical regression analysis and discrete choice experiment;QSR Nvivo 8 qualitative analysis software was used to analyze qualitative interview data.Main Results1.Institutional policy arrangements and applicationsThe institutional arrangements of FDCS were as follows:the government formulates and initiated the guidelines for FDCS policies,and unites the Human Resources and Social Security Departments,the Civil Affairs Departments,the National Development and Reform Commission,and the Administration of Traditional Chinese Medicine to provide policies and resource guarantees for FDCS.The government entrusts primary medical institutions and primary medical staff to jointly form a team to provide services of FDCS.Through incentive measures such as payment,assessment and supervision,the government ensures that the institutions and family doctors of FDCS provide qualified contracted services and improve the overall health of residents.The current FDCS service provision mode in Shandong Province was"1+1+1",and the family doctor team was consisted of village doctors,township health center doctors and county hospital doctors.Generally,doctors from the township health center were team-leaders,and doctors from the village clinic provided FDCS services directivity.Residents signed a FDCS agreement with the township health center and received primary public health services,medical services,and health management provided from family doctor teams.The main problems emerged in the government operation mechanism are as follows:(1)Unbalanced resource allocation and poor accessibility of comprehensive service provision.The construction of information system and supply of essential drugs in primary health institutions were imperfect.The results indicated that 76.67%of township health centers failed to share the residents’ health information with higher-level medical institutions,and more than half of village clinics have the shortage of essential medicines.(2)The two-way referral system has not been fully established which led to lack of continuity in FDCS services.Most village clinic doctors received insufficient work support from higher-level hospitals.And primary doctors were lack of specialized medical resources,referral resources,clinical experience and skills.2.FDCS implementation status from supply-side and demand-sideThe results from supply-side indicated that family doctors mainly have encountered challenges such as low capability,high workload and pressure,low income and salary perception,and low job satisfaction.(1)The education level of family doctors in village clinics were low.Only 1%of village doctors have received a bachelor degree or above.Most rural FDCS doctors have no professional title(65.68%)or only have a rural doctor certificate(56.09%).Only 34.32%of rural FDCS doctors had participated in general practitioner training programs.The proportion of rural family doctors who had sufficient knowledge and abilities in service provision was 15.50%.More than 80%of rural family doctors have encountered technical problems in the process of carrying out basic medical services.(2)The assessment mechanism and incentive mechanism of FDCS were not perfect.The workloads of family doctors were heavy with an average of 11 hours working per day and managing more than 1,500 people.93.36%of rural doctors feel that their workload has increased after participating in FDCS.And doctors were generally underpaid.Only 12.18%of rural FDCS doctors believed their salary matches their job,and there was significant income gap between family doctors in township health centers and village clinics.(3)The logistic regression results of FDCS doctor satisfaction indicated that the professional title,income,workload and work pressure of family doctors,technical support from county hospitals were significant at the level of 5%.The research results from the demand-side are as follows:(1)The overall signing rate of FDCS was low.Residents showed insufficient awareness of FDCS policies which lead to low contracting rate and service usage.The signing rate of FDCS in the sample area was 23.8%.Residents have a low awareness rate of FDCS,and 55.69%of the respondents have not been informed with FDCS services.Additionally,residents were unwilling to sign contracts due to lack of trust with capabilities of FDCS team and charges.(2)The results from the residents’ discrete choice experiment indicated that rural residents were more willing to select a FDCS doctor team with a high level of diagnosis and treatment(β=2.44),good service attitude(β=1.42),high availability of basic medicines(β=1.09)and an appropriate medical insurance reimbursement ratio(β=0.45).The results of the simulation of the FDCS contract signing showed that the signing rate was highly correlated with the cost.The signing rate will increase to 84%if the contract fee reduced from ￥200 to free.(3)Multi-level model results indicated that,at the individual level,the higher the level of education(OR=1.69),the more frequent physical exercise(OR=1.37)and the residents who more likely suffer from multiple chronic diseases(OR=1.53)were willing to sign FDCS contracts.At the village clinic level,the better informatization degree of village clinics(OR=1.31)were associated with higher contracting probability.At the township hospital level,the sufficient supply of essential medicines(OR=1.53),good information technology(OR=1.28),and participation in FDCS training program(OR=3.19)and being central health centers(OR=1.92)were related to higher contract rate.3.Deviations and Attributions in the Implementation of FDCSThe implementation deviations of FDCS are as follows:(1)The supply and demand of FDCS are not matched,that is,the residents’ health needs and preferences have not been responded to and met through the existing FDCS service provision.(2)Distortion of supplier incentives,that is,the existing fund-raising payment,supervision and evaluation system,result in low job satisfaction of FDCS doctors,and valuing quantity and despising quality in FDCS service provision.The impact of institutional arrangements on the deviation of institutional implementation mainly includes:(1)The government has failed to ensure the operation of the FDCS system.Incomplete of information system construction,drug supply guarantee,and training program have led to unfair allocation of health resources,vertical inequality in health service delivery capabilities and quality,and reduced the sustainability of the implementation of FDCS.(2)Residents cannot freely choose the FDCS contracted team,resulting in a lack of competition between teams,which is not conducive to the team’s improvement of service quality and the satisfaction of contracted residents.Hence residents have a low sense of service acquisition.In terms of the accountability mechanism,the lack of government’s rewards and punishments,supervision and assessment for FDCS doctors,and insufficient incentives have reduced the willingness of the FDCS doctor team.The formulation of FDCS service agreement does not meet the health needs and preferences of residents.The irregular pricing of service packages and unreasonable service content have led to a low signing rate,and the phenomenon of "signing without serving" is common.(3)The FDCS service agreement is a principled agreement,which has limited binding force on the FDCS doctor’s behavior.The influence of the deviation of system implementation on agent level on mainly comes from two aspects:multi-agent and common agency:(1)There were multiple agents within FDCS.The responsibilities,assessments,rewards and punishments have not been clearly defined which led to a lack of cooperation between different agents within the team,especially resulted in that the doctors from higher-level hospitals lack professional guidance to the primary-level medical staff.This can easily lead to a "free rider" phenomenon.And the overall utility of the client is reduced,resulting in low synergy of the system,and deviating from the goals of FDCS.(2)Family doctors are the joint agents of the government and the residents.The government is in an absolute strong position relative to the residents.If the tasks and goals assigned to family doctors by the government and the residents are inconsistent,family doctors would choose to pay more efforts for the strong client,that is,the government.And this will reduce the co-agent efficiency.At present,in the implementation process of FDCS,the government evaluated family doctors with workload indexes(contracts signing rate,coverage of FDCS)merely with quality indexes,which is different from the service quality preferred by residents.Therefore,family doctors would choose to first complete the work assessment goals set by the government,and ignoring efforts to improve service quality.This leads to the mismatch between supply and demand,and low residents’ sense of acquisition.ConclusionsTo improve the operating efficiency of FDCS,the government have to improve policy operation mechanism to enfore health resources allocation and establish supportive policies.However,the government’s supportive policies and the capacity of primary health services were insufficient,which severely hindered the implementation of FDCS.Additionally,the FDCS doctor team were characterized with multi-agents which leads to the neutrality of the agents within the team and lack of competition between the teams,and lowered the FDCS efficiency.Besides,the government has not established an appropriate reward and punishment mechanism,incentive mechanism which decrease enforceability of FDCS.Family doctors did not aim to maximize the benefits of the contracted residents which caused the FDCS doctor’s behavior to deviate from the residents’ interest goals.In addition,the lack of supervision and information disclosure channels has resulted in asymmetric information between providers and demanders.Finally,lack of mutual accountability mechanisms between the government,doctors,and residents has also exacerbated the inconsistency of objectives between the principal and the agent.Policy implicationsIn order to resolve the challenges emerged in the implementation of FDCS and improve health-care service quality provided by family doctors,this study proposes the following policy recommendations:1)Elicit and provide appropriate and personalized health-care services so as to in accordance with residents’ health preference and demand;2)Improve capabilities of family doctors as well as capacities of health-care facilities by health-care resource allocation to grass-level regions;3)Strengthen the"gate keeper" function of family doctors with two-way referral policy and relative institutional policies;4)Establish a sustainable financing mechanism provide financial support for FDCS;5)Construct appropriate evaluation and assessment scheme and clarify responsibilities of family doctor team members;6)Improve FDCS implementation performance by pay-for-performance and quality competition among different family doctor teams;7)Enhance administration collaborations among government to enforce mutual accountability and improve responsiveness of FDCS;8)Improve quality and efficiency of FDCS by contracting management.Strengths and limitationsStrengths:1)This study focus on three key actors in the FDCS implementation process,namely,government,family doctors,and residents.We have applied comprehensive analysis of FDCS with respect to the institutional operation mechanism,funding and payment mechanism,evaluation and assessment mechanism,and mutual accountability mechanism.2)The study has applied principal-agent theory and strategic purchasing theory to construct the analysis framework,and analyzied the principle agent relationships among government,family doctors,and residents;3)The study used mixed method which combined quantitative study and qualitative study,and used discrete choice experiment with multi-level statical model too reveal the underlining logic of policy implementation.Limitations:1)The data we have collected has some bias.In the future study,we will increase sample size to overcome this bias;2)Due to the limitation of discrete choice experiment,the attributes we have selected may not cover all factors which may affect residents’ preference;3)This study only selects Shandong Province as the research site.Shandong Province is located in the eastern part of my country and is a relatively developed province,which cannot fully represent the provision and utilization of health services in the backward and remote areas of western my country.In future research,we can select economically developed provinces and underdeveloped regions to conduct comparative research on contracted services. |
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