The Effective Of County Medical Community Reforms On Service Capacity Of Primary-level Healthcare Institutions And Its Mechanism

After the new healthcare reform,“bolstering the primary-level” is regarded as the fundamental way to resolve the problem of "difficultly and expensively seeking medical treatment".More input as the government has contributed into "bolstering the primary-level" over the years,due to the long-term solidified interest pattern of the medical service supply-side and the fragmentary policy supply system,China’s primary-level health institutions are still facing salient problems such as: debilitating medical functions,insufficient allocation of high-quality resources,inflexible operation mechanisms,inappropriate financial compensation system along with financial incentives,and deficient talent introduction.Those problems severely restrict the advancement in the service capacity of primary-level healthcare institutions.In the interaction between local exploration and top-level design on "bolstering the primary-level",China has found an integrated health service system reform plan,the core of which is the county medical community reform.In 2019,the National Health Commission issued a document requiring the initial establishment of the medical community in 500 counties across the country by the end of 2020.The reform of the medical community,which is in full swing in practice,is disconnected from theoretical research.In the previous research,the integrated reform models with their countries of origin,European and American,have been studied or paid attention to,as well as the experience of domestic reform practice in summary.However,the theoretical system applicable to China integrated health service system reform has been neglected.Meanwhile,the advancement in the service capacity of primary-level healthcare institutions is the goal of the integrated reform,but few studies associate the two to investigate the causal relationship and logical chain.Based on that,this paper aims to answer those questions below.Has the reform of integrated health service system improved the service capacity of primary-level healthcare institutions?How do different governance-dimensions of the reform influence separate aspects of service capacity of primary-level healthcare institutions? What is the mechanism of this influence? Predicated on the neo-institutional theory,this paper,constructing an analytical framework from the perspective of "institution-structure-capacity",aims to investigate how the integrated health service system reform affects the service capacity of primary-level healthcare institutions through incentive mechanisms,as an institutional arrangement.The integrated health service system reform will have multiple positive effects on the service capacity of primary-level healthcare institutions.With the data on the health service capacity of 350 primary-level health institutions from 2017 to 2020,and the use of the Difference-in-Difference Model to evaluate the net effect of the reform,it can be found that the service capacity of primary-level healthcare institutions has been significantly improved before and after the time point of the medical community reform.The regional heterogeneity has a regulatory effect on this impact.Through the questionnaires on county medical community reform issued at the end of 2021,the current situation of county medical community reform is matched with the service capacity of primary-level healthcare institutions that year.The regression results of the Ordinary Least Squares show that different governance-dimensions of the reform have distinct effects on different aspects of service capacity of primary-level healthcare institutions to varying degrees.In terms of service provision,the degree of government power transfer,the degree of decision-making autonomy,the degree of scientificalness in the fundraising and payment design and the level of integration of organization and management have positive correlation with the service delivery capacity at the primary-level.In terms of organizational growth,the degree of government power transfer and the degree of scientificalness in fundraising and payment design have positive correlation with the potential of organizational growth at the primary-level.In terms of client attraction,the degree of government power transfer,the degree of decision-making autonomy and the level of organizational management integration have positive correlation with the capacity of client attraction at the primary-level.In terms of performance incentive,the degree of government power transfer,the degree of decision-making autonomy and the level of organizational management integration have positive correlation with the performance output ability at the primary-level.Three mechanisms are there for the impact of integrated health service system reform on service capacity of primary-level healthcare institutions: co-governance mechanism by plural subject,empowerment mechanism by information technology,and incentive compatibility mechanism.Through field research and on-site interviews about medical community reforms led by around 30 county medical communities in Zhejiang Province,county medical communities in Yuncheng City in Shanxi Province and Tianchang County in Anhui Province,it can be found that under the action of the co-governance mechanism by plural subject,relationships between relevant stakeholders have been reshaped,in the operation mechanism of primary-level healthcare institutions.On the one hand,the medical community has stimulated the autonomy of medical institutions at all levels to actively offer high-quality medical services via corporatization of the group;on the other hand,the modernizing hospital management system will improve the competition in the healthcare service market to a certain extent,and promote plural subject like socially-run healthcare subject to increase the effective service supply.Under the role of the empowerment mechanism by information technology,information technology realizes the division of labour and cooperation among healthcare institutions at different levels in the integrated body,and increases the efficiency of regional healthcare resource utilization.This can not only ameliorate residents’ medical experience and standardize medical treatment behavior,but also enhance the effectiveness of primary-level healthcare institutions.Under the role of incentive compatibility mechanism,the reform of the integrated medical-insurance payment system and the reform of the personnel-authorized arrangement system can maximize the benefits of various stakeholders through economic and non-economic incentives.Driven by the community of shared interests,various entities enhance the willingness to provide services and the motivation for higher performance output.To realize the integrated health service system reform and continuously improve the service capacity of primary-level healthcare institutions,promoting the transformation of "medical community" to "health community" is necessary.First of all,dilute the concept of "service capacity of primary-level healthcare institutions" and emphasize the advancement in "service capacity of county medical community".Through the reform of the county medical community,primary-level healthcare institutions have inevitably had the " ability element" of county hospitals.Therefore,it is necessary to investigate the improvement of health service ability and the utilization of health resources from the county level.Secondly,from co-governance mechanism by plural subject to interactive collaborative governance.In the innovation of public governance in the county medical community reform,the administrative mechanism,market mechanism and community mechanism should be embedded together and play a synergistic role.Thirdly,government need to promote the continuous empowerment of information technology and digital health reform.Government departments need to respond to public demands with digital cognition,innovate the system and mechanism of linkage of health service system,health financing system and drug supply system through digital thinking,strengthen information operation and management,and build a "digital medical community".Finally,in the comprehensive operation mechanism,the first is to fully implement the reform of the financial compensation system based on the principle of government-purchase,and effectively integrate it into the medical community reform.The government-purchase is either paid on the basis of the position or calculated in equivalent.Financial compensation is directly entered into the unified financial account of the medical community,and a social third-party audit system is established for supervision.The second is to replace the total amount control of the original constituent units in the medical community with global budget system of the entire medical community.Adopt the incentive mechanism of "either defraying over-expenditure or retaining the balance" to remove various restrictions on the allocation of balance retention.Medical insurance institutions shift the focus of medical insurance audit from review costs to monitoring quality.Third,equip medical communities with full employment autonomy in personnel authorized management.The appointment functions of legal persons executives in the medical community are exercised by the corresponding councils.The full-time contract appointment system is implemented,and the examination and approval system of the medical communal system can be changed to the filing system.Harmonize the original and new establishments at the county-and-township levels into the management and use of the medical community.Actively encourage county(city,district)governments to carry out de-establishment reform.