| ObjectiveThis study sought to establish the assessment indicators system for the construction effect of the Hierarchical Medical System(HMS)in China,and appraise the construction effect of HMS from the national,provincial,district or county,and residents’(or patients’)levels,respectively.Based on above findings,we summarized the effectiveness and shortcomings of China’s HMS construction,and then proposed targeted policy proposals.MethodsFrom January to August 2019,we went to Pengshui County in Chongqing,Qiaokou District in Wuhan,Luohu District in Shenzhen,and Shanxi Province for field researches and investigated the typical practical experiences and creative measures in different regions.From March to April 2019,we conducted a questionnaire survey,namely,“Residents’ Utilization of Contracted Services by Family Doctors” among11250 participants in 31 provincial-level administrative regions across China.In addition,we further supplemented the missing data in previous surveys by contacting with the health administration departments of above regions via online or offline methods from October to November 2020 and May to July 2021.The domestic and foreign theoretical and empirical studies related to the construction of the HMS were collected by searching CNKI,Wanfang,CQVIP and Pub Med,Web of Science to understand the research status and trends of HMS’s construction;The websites of the health administration department were searched to collect relevant policy documents,the Health Statistics Yearbook and the Statistical Bulletin of the Health Development,to grasp the policy concerns and development status of the HMS in China;The evaluation index system for the construction effect of China’s HMS was built by collecting relevant indicators from policy documents and previous studies,which was combined with the index screening principles and results of experts’ consultations.With data collection,descriptive statistical analyses,trend analyses and linear regression had been applied to assess the construction effect of HMS from the national,provincial,district and county levels.Furthermore,descriptive statistics,mixed-effects model,and multiple stepwise logistic regression were used to analyze residents’(or patients’)trust in family doctors,satisfaction with family doctor services and willingness to maintain contracts with family doctors.Results1.Establishment of the assessment indicators system for HMS’s constructionThe established assessment indicators system for construction effect of China’s HMS includes 3 first-level indicators,9 second-level indicators,and 49 third-level indicators.The importance and feasibility of all the indicators have average scores greater than 4.00,the coefficient of variation are less than 0.25,and the Content Validity are all appropriate(I-CVI ranges from 0.786 to 1.000;S-CVI/Ave is 0.927).2.Evaluation on the construction effect of HMS2.1 National level.With the development of HMS’s framework,numbers of medical and health institution(9.93%),health personnel(66.14%),hospital bed(99.41%),income(291.48%),and patients served(58.90%)in China have increased significantly from 2009 to 2019.However,the overall effect of HMS construction remains limited.For example,the proportion of the primary healthcare visits in the total number of visits has been decreasing with an average annual rate of 1%.2.2 Provincial level.Shanxi Province takes the “Integration Reform of County and Township Medical and Health Institutions” as its starting point to promote the HMS’s development.From 2014 to 2019,numbers of medical and health institutions(3.40%),health personnels(18.11%),hospital beds(23.11%),income(73.20%)and the downward referrals in Shanxi Province have been enriched continually,but the capacity of primary healthcare is still insufficient,and its medical resource allocation structure also needs to be optimized.2.3 District and county levels.From 2014 to 2019,numbers of community healthcare center(43.48%),health personnels(81.01%),hospital beds(86.63%),income(163.77%)and residents contracted with family doctors(505.75%)in Luohu Hospital Group have increased gradually;Through implementation of “Qian Fang Bai Ji” projects and development of specialized specialties in primary healthcare centers,numbers of medical and health institutions(80.49%),health personnels(85.99%),hospital beds(49.03%),income(74.83%),medical consortiums(55.56%),residents contracted with family doctors(264.03%)and bidirectional referrals(27.23%)in Qiaokou District have benn improved;With the group management of primary healthcare institutions and the construction of “Funding Pool”,numbers of medical and health institutions(4.73%),health personnel(37.06%),hospital beds(79.69%),income(83.82%),bidirectional referrals(90.24%)and patients served(10.25%)in Pengshui County have all increased to varying degrees.Overall,the construction measures of the HMS in each district or county have their own characteristics and have achieved certain results,but the overall effects are not satisfactory and still needs to be further improved.3.Residents’(Patients’)trust in family doctors,satisfaction with family doctor services,and willingness to maintain contracts with family doctorsA total of 11250 residents(patients)were included in this study.Among them,71.38% participants trust in family doctors,68.90% participants were satisfied with family doctor services,and 71.25% paticipants were willing to maintain contracts with family doctors.Local household registration(Odds Ratio(OR)=1.192),enrolling in medical insurance(OR=1.299),better self-report health status(OR=1.246),shorter walking time to the nearest healthcare institution(<15 minutes:OR=1.209;15～30 minutes: OR=1.288),trusting in family doctors(OR=4.403),and satisfying with healthcare services by family doctors(OR=18.514)were suggested to increase residents’ willingness to maintain contracts with family doctors significantly.Conclusions and RecommendationsThe policy framework for HMS in China has been refining gradually,the construction model of HMSs in different regions has its own strengths,and the hardware conditions of primary healthcare institutions have been improved to some extent.However,the fundamental contradictions are rarely touched by relevant policies and practical measures.It is recommended to regulate the construction of China’s HMS by improving relevant laws and regulations,implementing the government’s responsibility,building a closer medical alliance,optimizing the allocation structure of medical resource and exploring the reform of medical insurance payment methods,to guide medical and health institutions,medical workers,patients and other stakeholders to participate in HMS consciously.In addition,it is suggested to appropriately draw on the experiences of the international HMS’s construction,combining it with the actual medical and health condition in China,to promote the steady and long-term development of China’s HMS.Innovations and LimitationsIn terms of study perspective,we comprehensively evaluated the effect of China’s HMS from four levels: the country,province,district or county,and residents or patients.The results have been presented by the combination of macro-and microperspectives,representative and applicability.In terms of evaluation index selection,we not only attempted to construct a comprehensive systemic index system,but also explored innovative evaluation indicators,such as residents’ willingness to renew family doctors.In terms of study findings,this study has obtained a number of innovative findings,which could supplement previous research findings.However,due to the complexity and on-going development of the HMS,plus various ideas and measures for HMS’s construction in different regions,the evaluation indexes selected in this study could not fully reflect the characteristics of HMS in every region.In the empirical research,we mainly use the longitudinal comparison method to evaluate the construction effect of the HMS for each sample region,instead of the parallel comparison or horizontal comparison.In addition,it is slightly insufficient to reflect policy perceiver’s evaluation on the construction effect of HMS from the prospective of their trust in family doctors,satisfaction with family doctors or willingness to maintain contracts with family doctors,further studies from other perspectives are necessary to conduct to increase the strength of the evidences. |
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