| Primary health care (PHC) systems play an important role in almost medical and health service system around the world. In2009, Chinese communist Party Central Committee and the state council launched a new round of health care reform, which would spend three years consummating PHC systems, strengthening construction of health human resources, and making efforts to improve service quality and levels in primary health care institutions (PHCIs). Strengthen the basic role of PHCIs as China’s medical and health service system, and make PHCI a good "health gatekeeper" for people. After three years, there were918thousand PHCIs around the country, owning1.234million beds, and the number of health professional increased to3.375million people. There were3.8billion visits in PHCIs, which accounted for60.8%of the total in2011. However, PHCIs are in face of many problems and challenges, and the problem of "the difficult medical services and expensive medical cost" has not been radically solved, which becomes more serious in some regions.Primary health care human workforces are the main carrier of the service delivery of basic medical care and health services and basic public health services, and are the base to build basic medical and health services system. Total health resources in a country are limited, and how to allocate these resources reasonably and equally, which is closely related to the improvement people’s life satisfaction and social harmony. Reasonable and equitable allocation of health resources has been a hot area of the research on a world scale. There are unequal allocations of health resources even in developed countries. While in poor developing countries, the problems of inequity of medical and health services become more prominent because of shortage of health resources. There are the problems of unequally distribution of health resources in China, especially in allocation of human resources in PHCIs. However, whether recent medical and health reform affected the allocation and equal distribution of health human resources in PHCIs has not been reported.This study described the allocation and evaluated the inequity of human resources based on cross-sectional study in community health service institutions (CHSIs) from some regions of the Jiangsu province. The study analyzed the trends in inequity in the distribution of human resources in PHCIs, the effect of health policies on the allocation of primary health human resources, and estimated the health human resources staffing levels of PHCIs by historical statistics to show the gaps in staffing levels in different cities in Jiangsu. The results would provide governments some reference on the development of health human resources in PHCIs.Part I Distribution and Equity of Community HealthService Human Resources of Parts of Regions in JiangsuThe study took a selective and random sampling method, selecting15community health service centers (CHSCs) with every station under these centers, and their health workforces from5cities in Jiangsu. The study investigated configuration status of human resources in each institution, and compared their structural characteristics in different cities. And then the study evaluated the inequity in the distribution of health workforces using gini coefficient, Atkinson index and the generalized entropy index, drawing Lorenz curve of the distribution of health workforces in CHSIs. The main results were as follows: 1. Distribution of health workforces in CHSIsThere were1208health workforces in15CHSCs, including966and health professionals accounted for79.97%(966/1208). Among the966health professionals, physicians accounted for40.89%(395/966), nurses accounted for36.44%(352/966), and the ratio of physicians to nurses was1:0.89. County doctors accounted for7.2%of all health workforces.The average of health professionals was36.73±11.19years old, Most of health professionals were under30years old (34.58%) and the30-to-39(34.16%) age group, and over60years old group accounted for3.73%of all health workforces. Most of physicians were from the30-to-39(39.49%) and40-to-49(24.05%) age group. The proportion of nurses under30years old (39.77%) and in the30-to-39(33.52%) age group was relatively higher. Most of health professionals were female (73.91%). The proportion of female was similar with male in all physicians, and all nurses were female.Most of health professionals had college degree (37.89%) and bachelor degree (32.40%) education background. There were some health professionals below high school education level (20.19%). Physicians had higher education background than others, and there were56.71%physicians with bachelor degree or above. While most nurses had college degree (46.31%), and high school education level and below accounted for28.98%. There were54.24%health professionals with primary titles, and30.95%with secondary title. The ratio of senior titles, secondary titles to primary titles was1:5.4:9.5. There were statistically significant differences in composition of classification, age, gender, education background and titles from CHSIs in different cities (P<0.05).Public health professionals accounted for2.60%of all health workforces,0.4personnel per10,000people. 2. Inequity in the distribution of health professionalsThe gaps in the distribution of ownership of health workforces among5cities were relatively big. The CHSIs with the most ownership of health workforces per10,000people were from the Third center in C city (26.43personnel) which was the14.4times than the least (1.83personnel) from the First center in Z city. The CHSIs with the most health workforces (72.45personnel) per square kilometers were the Third center in W city, and the CHSIs with the least health workforces (0.66personnel) per square kilometers were from the Third center in X city. The Gini coefficient of health professional, doctor (including county doctor), physician and nurse across population were0.3234,0.3504,0.3543and0.3308, respectively, which were equal. While the Gini coefficient of health professional, doctor (including county doctor), physician and nurse across area were0.6127,0.5608,0.5975and0.6535, respectively, and there existed inequity in the distribution of health workforce across area. And the results of other inequity indices were similar.PART Ⅱ Trend in the inequity in the distribution of primary health care professionals in JiangsuThe second part included all types of PCHIs, to describe the development and trends in the distribution of human resources in PHCIs before and after health reform, and used several inequity indicators to evaluate the inequity in the distribution of health workforces by historical statistics from2008to2012. The study then estimated the staffing level of human resources in the target-year, and calculated the gaps in human resources staffing level between the current year and the target-year based on the principle of equity. The main results as follows: 1. Time trend in the number of health professionals in PHCIs in Jiangsu from2008to2012The number of health professionals had been increasing by about4.5%every year from2008to2012. The ownership of health professionals per10,000population increased from13.94to15.92personnel. The physician-nurse ratio was about1:0.54～1:0.61, and the physician-health professional ratio was about1:1.95～1:2.15. There were differences in the distribution of health professionals in different districts of Jiangsu from2008to2012. The change in ownership of health professionals per10,000was small in southern and middle Jiangsu, while the change in northern was larger, and the ownership of the northern Jiangsu was closer to the southern. The ownership of health professionals of Suqian lagged far behind the other cities.2. Time trend in measures of inequity of health professionals in PHCIsThree measures of inequity including gini coefficient, Atkinson index and Theil index showed a consistent of trend from2008to2012. From2008to2012, the measures of inequity across population and area in the distribution of health professional and physician showed decline trends. For nurses, the three measures of inequity across population showed downward trends as a whole, while the measures were worsen slightly in2012than in2010and2011. And three measures of inequity across area in the distribution of nurse declined since2009.3. Inequity of health workforces in PHCIs of all cities in Jiangsu in2012In terms of population, the number of health professionals per10,000population for the whole province ranged from a low of4.84(in Suqian) to20.25(in Huaian). With respect to area, health professionals per square kilometer ranged from0.27(in Suqian) to2.02(in Suzhou). The ownership of health professionals in Suqian was at the worst. In2012, the Lorenz curves representing the health professionals across population were closer to the diagonal of equality than the curves across area. 4. Estimation of staffing levels of PHCIs in the target-yearWe found that15-19health professionals and6-9physicians per10,000population as the standard for the staffing levels in2015, the average ownership of primary health care professionals in Jiangsu province in2012had reached the lower level of the target-year, but there was still a gap from the upper level. The ownership of Nanjing, Wuxi, Suqian did not reach the lower level of the corresponding cities, especially for Suqian. According to the standard of the ratio of physician to nurses (1:1), the staffing levels of all cities in2012had gaps from the lower levels of corresponding cities. |
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