| BackgroundThe modernization reform of China’s disease prevention and control system has been elevated to the national strategic level after the COVID-19 epidemic,and disease control resources are the basic conditions and material basis for effectively promoting the reform of the disease prevention and control system.Therefore,strengthening the allocation of disease control resources is an important part of the reform of disease prevention and control system.As the"net base" of China’s four-level CDC,county-level CDC play an important role in the modernization of the system in the post-epidemic era.Therefore,in the new era,how to rationally allocate human,financial and physical resources of CDC and improve the efficiency of resource allocation of CDC has been highly concerned by the government and the public.As a province with large economy and population,Shandong Province is also a pioneer in the reform of disease control and prevention in China.In recent years,Shandong Province has carried out many reform practices in the reform of public health system and the standardization construction of disease prevention and control institutions,and has achieved positive results.However,it still faces some problems such as weak capacity building,unreasonable resource allocation and poor performance of functions of grass-roots CDC.Therefore,this study aims to help further discover and clarify the problems and contradictions existing in the current disease control system in Shandong province by discussing the resource allocation status of countylevel CDC in Shandong Province,in order to provide empirical basis and theoretical reference for the formulation of relevant policies to futher deepen the reform of the disease control system and the formulation of regional health planning.ObjectiveThe purpose of this study is to explore and analyze the current situation and existing problems of resource allocation,efficiency and improvement path,optimization influencing factors,etc.of county-level CDCs in Shandong Province through theoretical and empirical research,in order to provide reference for the reform of the disease control system and the optimization of institutional resource allocation.Specific research objectives are as follows:1.Analyze the current situation and existing problems of human,financial and physical resources allocation,as well as the performance of basic public functions of county level CDCs in Shandong Province;2.To evaluate the resource allocation efficiency of county level CDCs in Shandong Province,and construct the improvement path;3.Explore the main influencing factors of resource allocation optimization for county level CDCs in Shandong Province;4.Put forward relevant policy suggestions on the reform of disease prevention and control system and the optimization of institutional resource allocation in Shandong Province.Data and MethodsDataThis study was conducted in county-level CDCs of Shandong Province.Data sources mainly includes three parts:(1)Questionnaire survey data.Based on the comprehensive consideration of regional differences and economic development level,20 county-level CDCs in Shandong Province were selected as sample institutions by stratified random sampling method.The selfdesigned questionnaire was used to collect the basic information,human,financial and material resource allocation and relevant data of basic public function performance of the sample institutions.(2)Semi-structured interview data of key insiders.A total of 217 people from 20 sample CDCs,including principals,department directors and staff,were selected as interview subjects by means of purple-oriented sampling and convenience sampling.Semi-structured interview outline was adopted for in-depth interview,and more than 600,000 words of interview data were collected.The first two parts of data were obtained by field research from 20 sample CDCs in Shandong Province from June 2021 to January 2022.(3)Data of macro-regional economic development,social development level and medical and health resources.It is mainly derived from public data such as China Health Statistical Yearbook,Shandong Provincial Statistical Yearbook and government financial statements.MethodsFirst of all,questionnaire survey data were used to understand the status quo of human,financial and physical resources allocation and the performance of public functions of sample institutions through descriptive analysis and comparative analysis.At the same time,based on the grounded theory,open coding,spindle coding and selective coding are carried out on the in-depth interview data,and finally the model is concluded to analyze the problems existing in the allocation of human,financial and physical resources.Then,the data envelopment analysis method(DEA-BCC)was used to evaluate the resource allocation efficiency of sample CDCs,and the comprehensive efficiency,pure technical efficiency and scale efficiency of resource allocation were analyzed.The difference ratio between the actual value and the projected value of each input and output index is compared,and the situation of "relatively excess input" and"relatively insufficient output" of each specific index of non-DEA effective institutions is clarified.Furthermore,on the basis of DEA research,configuration thinking and fuzzy set qualitative comparative analysis method(fsQCA)were used to construct a driving model of input-output efficiency of CDC from five condition variables of two factor dimensions,so as to find a combination path of efficiency improvement.Finally,using the method of the based theory,open coding,main axis coding and selective coding were carried out on the interview data of key sources in typical regions to sort out the logical relationship among influencing factors,form the influencing factor model of resource allocation optimization of county-level CDCs based on "system-mechanism-policy-environment",explain its mechanism of action,and put forward targeted optimization strategies and policy suggestions.ResultsResource allocation of county-level CDCs in Shandong ProvinceHuman resource allocation:(1)Status analysis:①In terms of the number of personnel,the average number of personnel in sample CDCs in 2020 was 75.90,which was 0.26%less than that in 2016.The average number of CDC personnel per 10,000 population was 0.94,all of which failed to meet the national standard,and only 6 CDCs reached the standard of Shandong Province.After the COVID-19 pandemic outbreak,the average staffing level of the sample CDCs was 1.13 per 10,000 population.Twelve CDCs met the Shandong provincial standard and two met the national standard,but the vacancy rate of some institutions was still high.The average proportion of health technicians was 75.68%,with 70.00%of institutions meeting the standards;the average proportion of professional technicians was 85.89%,with 80.00%of institutions meeting the standards.②In the aspect of personnel quality structure,more female staff,accounting for 52.04%;The age group is mainly 37 to 55 years old,accounting for 61.46%,and the problems of "aging" and "age fault" are more prominent.The educational structure was improved,with bachelor’s degree accounting for 56.32%.The titles were mainly intermediate and junior titles,accounting for 40.12%and 33.14%respectively,and the difficulty of promotion was still prominent.The proportion of preventive medicine professionals was 33.00%,and the proportion of non-preventive medicine medical-related professionals was 48.62%,and professional mismatch was still common.The average score of comprehensive quality of personnel was 7.53,and east>central>west,district genus>county genus.③In terms of personnel outflow,the total number of personnel outflow reached 27 in 2020,mainly due to retirement,admission to medical institutions/superior CDC/government agencies,and the eastern,central,county-level city(district)affiliated institutions personnel outflow were more serious.(2)Common problems:Based on grounded theory,the PIP models of human resource allocation obstacles and problems in county-level CDCs of Shandong Province were constructed(Obstacles of Personal and Security,Obstacles of Institution and developmental,Obstacles of Policy and Input).The analysis results show that personal and security obstacles mainly include:low salary,high work intensity,low job accomplishment.Institutional and developmental obstacles mainly include:insufficient number of personnel,poor quality structure,introduction difficulties,high risk of loss,imperfect institutional management mechanism,lack of personnel training,etc.Policy and input barriers mainly include:insufficient policy support,insufficient government financial input and other factors.Due to various factors,county-level CDCs are trapped in a circular dilemma of insufficient staff,weak service ability,unstable talent team and difficulties in improving service quality.Targeted measures are urgently needed to solve these problems.Allocation of financial resources:(1)Status analysis:①In terms of institutional income,the average income of 20 sample institutions showed an increasing trend year by year from 2011 to 2020.The average annual income of institutions in 2020 was 40.540,500 yuan,an increase of 276.40%compared with 2011,with an average annual growth rate of 0.16.From 2011 to 2020,the composition of institutional revenue has changed greatly,with the proportion of fiscal appropriation increasing from 49.86%to 65.55%,and business income decreasing from 35.47%to 23.18%,indicating an improvement in the income structure.Government financial appropriations and personnel financial appropriations were increased year by year.② In terms of institutional expenditure,the average institutional expenditure in 2020 is 39,5175 yuan,an increase of 265.3 3%compared with 2011,with an average annual growth rate of 14.51%.In the past ten years,institutional expenditure has shifted from project expenditure to basic expenditure.In 2020,basic expenditure and project expenditure will account for 65.93%and 34.07%on average.③ In terms of income and expenditure balance,the average income and expenditure balance of institutions in 2020 is-1.023 million yuan,showing the overall situation of "outcome beyond income".④ In terms of personnel salary,the average annual salary of personnel in the sample institutions in 2020 was 78848.85 yuan,an increase of 27.78%compared with 2016,and the central and eastern regions were higher than the western regions.However,employees’satisfaction with salary were low.60.70%employees were not satisfied with the current salary,and 80.5%employees thought their salary is lower than that of employees in other medical and health institutions.(2)Common problems:Based on the grounded theory,the 3M model(Macro,Medium and Micro)was constructed for the problems in the allocation of financial resources in the countylevel CDCs in Shandong Province.The analysis results showed that the problems county-level CDCs faced at the macro level were also the key problems of the disease control and prevention system reform,including:the lack of government public product financing function,long-term stable investment mechanism need to be further established;In the medium level,the main problems are the limited financial capacity and the lack of input power of local governments.At the micro level,it mainly faces such problems as insufficient personnel funds,insufficient operational funds,low personnel salary and treatment,and imperfect financial management system of the organization.Material resources allocation:(1)Status analysis:① In terms of infrastructure such as housing,75.00%of the 20 institutions reached the standard of building area,30.00%reached the standard of the proportion of experimental room area,and 55.00%reached the standard of the per capita working room area.Laboratory room construction needs to be further improved;② In the configuration of instruments and equipment,among the 5 types of items in the sample institutions in 2020,the conforming rate of laboratory instruments and equipment was 100.00%,that of health education equipment was 40.00%,that of information equipment was 10.00%,that of vehicles was 95.00%,and that of cold chain equipment and equipment was 20.00%.It has Class A instruments in an average of 31.45 categories and 70.10 sets;Class B instruments 14.60 categories and 25.30 sets,Class C instruments 8.55 categories and 11.10 sets.The overall routine work required for the configuration of instruments and equipment has not reached the national standard(more than 90.00%),which need to be further improved.(2)Common problems:Based on grounded theory,A QQUM model was constructed for the problems existing in the allocation of material resources in Shandong county-level CDCs.The analysis results show that in the quantity dimension,there are mainly problems such as substandard total building area,insufficient laboratory space,substandard equipment configuration and excessive configuration of some instruments and equipment.In the quality dimension,the main problems are old buildings,unreasonable building layout,delayed updating of instruments and equipment,and poor quality of some instruments and equipment.In the utilization dimension,there are mainly low utilization rate caused by poor quality,low utilization rate caused by overallocation,low utilization rate caused by changes in disease control responsibilities,and low utilization rate caused by personnel problems.Matching degree is a higher requirement for the allocation of material resources on the basis of quantity and quality.It is also a key factor to improve the utilization rate of resources and promote the ability of disease control institutions.It is mainly reflected in the degree of matching between instruments and functions.The matching degree of laboratory occupancy and equipment;Laboratory personnel and equipment matching degree;The matching degree between the equipment list and the actual demand.Functional performance status of county-level CDCs in Shandong Province:In terms of basic public function development,the overall public function development rate of 20 sample institutions in 2020 was 87.12%;The seven basic public functions from high to low are public health emergency response,technical management and applied research guidance,health education and health promotion,disease prevention and control,laboratory testing and evaluation,epidemic and health-related factor information management,and health hazard factor monitoring and intervention,respectively ranging from 99.60%to 72.13%.(2)In terms of functional implementation,the overall implementation degree of public functions of sample institutions in 2020 is 79.00%.From the perspective of regional distribution,the implementation degree of central and eastern regions is higher than that of western regions.In terms of functional completion,the overall degree of functional completion is 68.60%,which is lower than previous studies.Resource allocation efficiency and improvement path of county CDC in Shandong ProvinceBased on the input-output index system of resource allocation efficiency of CDC constructed in this study,the analysis results using the DEA-BCC model showed that the average comprehensive efficiency of 20 sample county-level CDCs in Shandong Province was 0.934,but only 7(35.00%)institutions achieved overall effectiveness.The average technical efficiency was 0.963,with 14(70.00%)institutions achieving technical efficiency.The average scale efficiency was 0.969,but only 30.00%of the scale efficiency increased.From the perspective of regional distribution,the comprehensive efficiency of the eastern region was relatively good,and there was little gap between the central and western regions.However,the proportion of non-effective units in the eastern,central and western regions is high,which respectively were 66.67%,62.50%and 66.67%.It indicated that there wre still some countylevel CDCs in Shandong Province that had not fully implemented the corresponding responsibilities,played the emergency function,and could not properly and effectively use the input resources to improve the output at the technical level,and there are widespread problems of insufficient resource utilization or insufficient output.With comprehensive efficiency as the result variable,this study uses fsQCA method to construct an analysis framework from multiple dimensions of manpower,financial resources,material resources and social environment,and puts forward three efficiency improvement paths,namely "human-oriented","capital-oriented" and "material-resource-regional economic situation co-oriented",with coverage reaching 62.10%.In the "human-oriented" path,two subpaths were constructed,namely path la and 1b,with the high proportion of health technicians,non-high per capita fixed assets and non-high government support as the core combination of conditions.Path 1 a represents that the core conditions are high proportion of health technicians,low per capita fixed assets and low level of government support,and the marginal conditions are low level of complementary per capita financial appropriation.The typical representative institutions are Shan County CDC and Juye County CDC.Path lb represents that the core conditions are high proportion of health technicians,low per capita fixed assets and low level of government support,and high per capita GDP of complementary regions is marginal conditions.Typical representative institutions are Zoucheng CDC and Shouguang CDC.In the"material resources-regional economic situation co-leading" path,the core condition is that the per capita fixed assets and regional per capita GDP are both high,the government support is not high,and the complementary per capita financial appropriation is high,and the typical institution is Zhangqiu District CDC.In the "capital-oriented" path,the core conditions are the three highest levels of per capita financial allocation,per capita GDP and government support,the non-high proportion of health technicians and the non-high per capita fixed assets.The typical institution is the West Coast New District CDC.Influencing factors of resource allocation optimization of county-level CDCs in Shandong Province.By analyzing the in-depth interview data of the person in charge of the sample county-level CDCs and applying the grounded theory,the influencing factors of resource allocation optimization in Shandong county-level CDC were discussed.Research showed that scientific management system,smooth operation of mechanisms,systematic policies and supportive internal and external environment were important factors of influencing the optimization of resource allocation for CDC.All factors not only form their own systems but also interact with each other,jointly affecting the optimization of resource allocation for CDC.The scientific of the management system includes three dimensions:coordination degree of management mode,clarity of division of rights and responsibilities,and clarity degree of functional positioning.At present,there are problems such as division of divisions,unequal rights and responsibilities,and isomorphism of responsibilities,which need to be further clarified.The flexibility of operation mechanism includes three dimensions:management standard degree,medical and preventive cooperation degree,and information collection degree.At present,the internal management factors and driving force of institutions are insufficient,and the inter-institutional cooperation mechanism needs to be established.The system of policy system includes two dimensions:policy coordination degree and policy innovation.The supporting nature of internal and external environment can be divided into the supporting nature of external environment and the supporting nature of internal environment.The supporting nature of external environment mainly includes two dimensions:the degree of government importance and the degree of social recognition;The support of internal environment mainly includes three dimensions:personnel fitness,financial support and equipment and facilities.At present,the CDC is faced with problems such as the need to strengthen the government’s attention and insufficient policy support,which have affected or even hindered the optimization of institutional resource allocation.Conclusion and SuggestionConclusion(1)From the perspective of resource investment,the overall allocation of human,financial and material resources of county-level CDCs in Shandong Province has reached a certain scale,but there is still a large room for improvement in the resource allocation of some institutions.From the perspective of resource elements,the number of CDC personnel per 10,000 population,the proportion of preventive medicine professionals,government financial allocation,infrastructure allocation,equipment and equipment allocation rate still lag behind the allocation standard to a certain extent.(2)From the perspective of resource output,68.60%of the basic public functions of institutions were fulfilled,which was poor,and the most prominent problem was in the monitoring of health hazard factors.(3)From the perspective of resource allocation efficiency and improvement,the proportion of comprehensive effective institutions in resource allocation of county CDC in Shandong Province needs to be improved,among which the pure technical efficiency value is higher and the scale efficiency value is lower.There are generally insufficient utilization of input resources and relatively insufficient output.With the goal of efficiency improvement,based on the analysis framework constructed from multiple dimensions of human resources,financial resources,material resources and social environment based on configuration thinking,three efficiency improvement paths of Shandong county-level CDC were proposed,namely "humanoriented","capital-oriented",and "material-resource-regional economic conditions cooriented",with the coverage reaching 62.10%.(4)From the perspective of influencing factors of resource allocation optimization,key obstacles to resource allocation optimization of county-level CDC in Shandong Province include:lack of scientific management system,lack of flexibility in mechanism operation,lack of systematic policies and systems,and lack of support from internal and external environment.All factors not only form their own systems but also interact with each other,jointly affecting resource allocation optimization of CDC.Suggestion(1)Taking people’s health as the center,speeding up the supply-side reform in the health sector:Implementing the work policy of "prevention first" and always giving top priority to people’s health.Clarify the main responsibilities of the government,accelerate the supply-side reform in the field of disease prevention and control,and include the guarantee of disease control institutions in the government assessment.(2)Consolidating the supporting role of basic resources and strengthening the supply of key resource elements:moderately increasing the total number of CDC personnel,optimizing the personnel quality structure,and improving the personnel management system.Increase government financial input reasonably and establish a stable and suitable long-term investment mechanism.Improve the configuration of equipment and facilities based on functional requirements to improve the utilization rate of instruments and equipment.(3)Promote scientific evaluation of resource allocation for disease control and improve resource allocation efficiency according to local conditions:Balance scale,quality and efficiency to promote scientific evaluation of resource allocation.Give play to the active role of the main body,according to local conditions to choose the development path to adapt to their own actual situation.(4)To innovate the reform of the system and mechanism,and increase policy support:(1)strengthen the "block" coordination,implement the main responsibility,and highlight the key responsibilities of county-level disease control;(2)Strengthen the internal management of institutions and explore the establishment of effective medical and preventive coordination mechanism;(3)Adhere to the problem-oriented,activate the policy stock and give consideration to policy innovation.Innovation and LimitationInnovation(1)This study focused on the county-level CDCs in Shandong Province.Based on the complete analysis framework of "input-output-evaluation-optimization",the current situation,problems,efficiency and optimization strategies of resource allocation were discussed from a full dimension,so as to make up for the deficiencies of current county level CDC research to a certain extent.(2)In this study,qualitative and quantitative research methods are comprehensively used,especially the application of grounded theory in the problems existing in the allocation of human,financial and material resources and the influencing factors of resource allocation optimization.At the same time,configuration thinking and fsQCA were introduced for the first time into the research on improving efficiency of resource allocation for CDC,which to some extent made up for the deficiencies of previous studies on single factors.(3)In this study,based on the characteristics of county-level CDC,based on the grounded theory,the PIP model with problems in human resource allocation,the 3M model with problems in financial resource allocation,the QQUM model with problems in material resource allocation,and the "system-mechanism-policy-environment" model with problems in resource allocation optimization were constructed.Moreover,based on configuration thinking and fsQCA research results,three efficiency improvement paths of CDC were proposed,namely"human-oriented","capital-oriented",and "material resources-regional economic conditions co-oriented",which provided more path choices for CDC to improve the efficiency of resource allocation based on its own conditions.LimitationDue to their theoretical level and knowledge reserve,the research field of vision,the method using factors such as constraints,this study has some shortcomings:(1)Limitations of sample size Due to the fact that the study was carried out during the period of the novel coronavirus epidemic,travel was inconvenient and the CDC was busy.In order to fully guarantee the quality and authenticity of data,the data in this study were obtained from a first-hand survey.Limited by human resources,material resources and financial resources,institutional data with a large sample size could not be obtained.In the future,we can apply for related research projects to support more extensive and in-depth investigation and research.(2)Limitations of index selection This study failed to adopt the method of expert consultation to determine the evaluation index system,so the evaluation results of resource allocation efficiency of county level disease control agencies in Shandong Province have certain limitations.Future research will adopt the combination of qualitative and quantitative methods to determine the evaluation index system of resource allocation efficiency,and construct the evaluation index system of resource allocation efficiency of county disease control more scientifically.(3)The model construction based on the research method of grounded theory needs to be further improved and perfected,which can be further combined with the research frontier of grounded theory.In the future,the grounded conclusions can be confirmed or falsified by combining the structural equation model to analyze the data of large and medium scale samples,or by combining the QCA method to analyze the configuration of typical case samples.In order to improve the extensibility of the research and the interpretation of the theory. 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