| SARS crisis reveals that the disease prevention and control system (hereinafter "the system") in China is too weak to meet the requirements for guaranteeing population health, facilitating economic development and establishing harmonious society. To enhance the system has been regarded as the priority in the next years by the government. Hence, it is necessary to find out what on earth the weaknesses of the existing system are, which of these weaknesses are principal, the harm, root and mechanism of the principal problem, to work out corresponding strategies and schemes, and to determine what technical supports are needed. Moreover, the first step for strengthening the system is to define its public functions and to demonstrate the manpower, financial resources and apparatus needed for accomplishing these functions. In this regard, inadequate systematic researches have been found in the country. Therefore, with the financial support from the research funds of the Chinese Ministry of Health (MOH), the task force conducts the present study.Study ObjectivesThe present study is aimed to (1) demonstrate quantitatively the principal problems confronted by the system and their impact, root and impediment; (2) work out quantitatively the fundamental strategies for resolution to these principal problems, make recommendations for reform and logistic procedures of reestablishing the system; (3) determine the key measures to reestablish the system with focus on the fundamental strategies, which includes defining the public functions of the Center for Disease Prevention and Control (CDC) at each administrative level, working out the manpower standard for the provincial, prefecture and county CDC, and developing the standards for financial resources and infrastructure of the system; (4) work on the function, manpower and financial resource needed for the primary health facilities to undertake the tasks of disease prevention and control.Research Methods and Data Sources1. Instructive research methodThe present study adopts the "scientific procedure for policy making" as the instructive research method, which includes the following 7 logistically relevant steps: (1) demonstrate the policy issues objectively; (2) analyze the influencing factors and root of these issues scientifically; (3) work out the policies targeting on the root of these issues scientifically; (4) demonstrate the feasibility of the policy strictly; (5) strictly and completely follow the scientific and logistic procedure of policy implementation; (6) scientific mechanism of policy assessment; and (7) effective mechanism of feedback and improvement. The present study is primarily associated with the first 3 steps.2. Data sources and collection methods(1) Sample areas and institutionsThe present study includes CDCs at different administrative levels, stations (or institution) of disease prevention and control, community health service centers, township hospitals and village clinics. In recognition of the geographic difference over the country, 8 provinces (municipal city) are selected based on the economic status, i.e. Shanghai, Zhejiang, Jiangsu, Hebei, Shanxi, Sichuan, Qinghai, and Guizhou. The provincial CDC, 10 prefecture CDCs, and 10 county CDCs are selected for each province. Totally, the present study conducts five rounds of investigations with different contents and valid samples.(2) Data collection methods1) Literature reviewComprehensive literature search has been conducted to collect internationally and domestically published articles, books, government documentation, statistics, and government bulletins about function, human and financial resource allocation of the system by searching databases (such as CBMDISC, Medline), libraries and visiting government agencies and websites. In total, 205 articles published between 1990 and 2001 in 8 key journals of health management in China (i.e. Chinese Primary Health Care, Chinese Rural Health Service Administration, Chinese Health Resources, Chinese Health Service Management, Chinese Journal of Public Health, Chinese health economics, Health Economics Research, and Soft Science of Health) are selected.2) Survey of current statusThe survey has been conducted in sample institutions to collect information about the quantity, allocation, and education status of human resource, annual income per capita, expense, regular and special funds appropriated by the government and revenues from services besides public goods etc in the last 5 years. With development of the research, further investigation is conducted in the sample institutions to find out whether or not, to what extent public functions and services are provided and to collect information about the currently available manpower, expected manpower, current and expected input and output, etc. In general, every CDC or primary health care facility needs to fill out one form for each survey.3) Experts' consultationExperts with abundant field experience and theoretical accomplishment from CDC, administration of disease prevention and control, and specialists of policy analysis in the field of disease prevention and control are convened for consultation. Through brainstorm and group interview, they recommend and modify the public functions and services of the system, demonstrate and complete the influencing factors of the human and financial resources allocation. There are 6 rounds of experts' consultation with 54 person times in total.4) Demonstration conferenceThe demonstration conference is convened once to confirm the public functions and services of CDCs at all administrative levels and primary health care facilities, the computational formula of the human and financial resources allocation, and the resolution to adjust geographic variance of human resource allocation. The participants are experts from provincial CDCs and division of disease control and prevention of provincial health departments all over the country.It is the principal of the study that collects, summarizes, and quantifies the qualitative information. In addition to the descriptive statistical methods, multivariable statistics such as factor analysis and multiple regressions is adopted for the analysis of quantitative data in the process of model establishment and simulation. Comparative analysis is conducted between the status in quo and the research conclusion, the domestic and overseas, among eastern, middle, and western parts of the county, and among four levels (i.e. province, prefecture, county, and grassroots) in the determination of standards for human and financial resources allocation.3. Data quality assuranceThe principal of the study and some experienced members of the task force are responsible for collecting, cleaning up, and analyzing the qualitative data.The quantitative information is collected through investigation forms, which are filled out by persons trained directly by the members of the task force. There are personnel designated to review the logic of the returned forms. The logistic mistakes, if any, are corrected either by returning the investigation forms to be filled out again or by clarifying via telephone. Computer program is developed to detect the logistic mistakes in the process of quantitative data entry. Designated personnel are responsible for quantitative data analysis. All the quantitative data are cleared up and analyzed without making changes to the original dataset.Study results1. The principal problem with the current system is the inadequate fulfillment of its public functions, which has to be resolved by taking strong efforts. There are two fundamental reasons for this problem. Firstly, the financial investment from the government to the system is insufficient and inefficient, which represents the improper financing of the government. Secondly, the current system of finance makes cost recovery the top priority for all CDCs because raising money by themselves is permitted, which represents the improper management of the government.2. The fundamental strategies to resolve the abovementioned problem are as follows. Firstly, what has to be recognized is that it is the responsibility of the government to raise funds for disease prevention and control, and to ensure sufficient investment in the related institutions to recover the cost for providing the public goods. At the same moment, the wages and compensation for persons working in the field of disease prevention and control should be guaranteed. Secondly, the operating efficiency has to be improved by enhancing management and reforminggovernmental investment mode. The following reform steps have to be followed in order to reestablish the system in China: (1) more attention from government should be given to the disease prevention and control; (2) appropriate investment from government for the disease prevention and control should be ensured; (3) the stability and efficiency of governmental investment should be increased; (4) the management mechanism should be reformed to improve the operating efficiency of CDCs; (5) personnel reform measures should be taken to attract and retain persons with high capability; (6) the services besides the public goods delivered by CDCs should be disposed with carefulness.3. The public functions of CDCs are allocated into 7 aspects, 25 categories, 78 contents and 255 items. The tasks and responsibilities of CDCs are different at national, provincial, prefecture and county level respectively. The health institutions at the grassroots level are supposed to undertake 13 items of infectious diseases prevention and control, 13 items of chronic non-communicable disease prevention and control, and 7 items of health information management. Such an allocation of the public functions has been widely accepted by CDCs nationwide.4. It is common for the CDCs all over the country that the abovementioned pubic functions have only been fulfilled to a very limited extent, which further varies with geographic distribution and administrative levels. Among all the public functions, the rapid response for public health emergencies is the most fulfilled while the surveillance and control of health risk factors is the least. The reason is thought to be directly related to the human and financial resources allocation.5. In order to fulfill the expected public functions of disease prevention and control and the detailed items in next 3-5 years, the benchmarked manpower value in average for provincial, prefecture, county CDCs is 336, 102, 33 respectively, which makes up to 61.1%, 84.3%, and 76.7% of the present positions respectively. Similarly, it is estimated that 140,016 persons are needed for all CDCs (including provincial, prefecture and county CDCs), which is 32.3% less than that at the end of 2002 (206,815 persons). The present estimate will be 47.3% less than the addition of the number at the end of 2002 and all the special institutes nationwide (59044 persons). Given the total population in China, the present manpower standard is only equivalent to 11.8% in United States and 8% in Russia.6. In order to fulfill the expected public functions of disease prevention and control and the detailed items in next 10 years, the benchmarked manpower value in average for provincial, prefecture, county CDCs is 386, 113, 38 respectively, which is 17.7%, 9.7%, and 20.8% smaller than the number of present positions respectively. Similarly, it is estimated that 159,086 persons are needed for all CDCs (including provincial, prefecture and county CDCs), which is 23.1% less than that at the end of 2002 (206,815 persons). The present estimate will be 40.2% less than the addition of the number at the end of 2002 and all the special institutes nationwide (59044 persons). Given the total population in China, the present manpower standard is only equivalent to 12.9% in United States and 8.7% in Russia. This manpower standard is more rational, stable and easier for operation than the abovementioned. Based on the manpower standard for provincial, prefecture and county CDCs, it is estimated that the standard for community health service facilities in urban areas and township hospital, village clinics in rural areas is 3-6 persons per 10,000 population.Thus, in total, 390,000-780,000 persons are needed for disease prevention and control at grassroots level nationwide.7. Under the condition that revenues from the services besides public goods are used for compensating reduced stafftrimmers, about 6.56 billion Yuan (RMB) is needed additionally every year for CDCs to accomplish the targets in the next 3-5 years. Three to five years later, when all the services besides public goods and reduced stafftrimmers are completely separated from CDCs, the government has to pay extra 3.65 billion Yuan (RMB) annually for settlement of those reduced stafftrimmers. When all the services besides public goods and reduced stafftrimmers are completely separated from CDCs, the government has to pay extra 8.5 billion Yuan (RMB) annually for CDCs to accomplish the 10-year targets. It is estimated that the financing standard for community health service facilities in urban areas and township hospital, village clinics in rural areas is 50,000-120,000 Yuan (RMB) per 10,000 population. Thus, in total, 6.5-15.6 billion Yuan (RMB) is needed nationwide.Innovation and application1. With public goods as the focus, the present study clearly defines the function of the system, the disease prevention and control tasks for national, provincial, prefecture, and county CDCs and the health institutions at grassroots level. The 2004 Revised Infectious Disease Law adopted the definition of functions in the field of infectious diseases prevention and control (see Appendix 3).2. The present study defines the public functions and the detailed items of the system (state, province, prefecture, county, and grass roots) including 7 aspects, 25 categories, 78 contents and 255 items, which has already been distributed for comments in the National Health Conference at the end of July 2003, uploaded to the website of MOH at December 25, 2003 for public remarks, and adopted as the documents at the National Conference of Disease Prevention and Control in April 2004 (see Appendix 2).3. The present study works out the standards of human and financial resources allocation for provincial, prefecture, and county CDCs and the health institutions at grassroots level, which are aimed to define the public functions and the detailed items of the system. Based on the study results of human resource allocation, MOH issued the Prescript for Personnel and Position for all CDCs, which has already been distributed for comments in the National Health Conference at the end of July 2003, adopted as the documents at the National Conference of Disease Prevention and Control in April 2004, distributed for comments in the National Health Personnel Conference in May 2004, and submitted to the office of Institution and Staffing Commission of the Central Committee of the Chinese Communist Party for review (see Appendix 5).4. The present study works out the standards of infrastructure for provincial, prefecture, and county CDCs, which are aimed to define the public functions and the detailed items of the system. The study results regarding laboratory establishment and improvement have been used to develop the Guidance for Laboratory Establishment of Provincial, Prefecture and County CDCs, which had been issued jointed by the Department of General Administration, MOH and thecorresponding department under the State Development and Reform Commission at July 23, 2004 (Paper No. 108).5. The present study recommends the fundamental strategies and reform steps for reestablishing the system. Based on these study results, MOH developed recommendations to establish the Administration of Disease Prevention and Control, which had been submitted to the office of Institution and Staffing Commission of the Central Committee of the Chinese Communist Party for review (see Appendix 1).6. The present study demonstrates and reconfirms that the principal problem with the existing system is the inadequate fulfillment of its public functions, of which the root and mechanism are thoroughly discussed and the simulation model is set up and improved.The Prescript for the Disease Prevention and Control System Establishment has been developed based up the abovementioned study results, which has already been distributed in the No. 40 Order of Health Minister at January 5 2005 with the agreement from the Ministry of Finance. Starting from 2005, MOH launches the training course of the management skills for provincial and prefecture staffs, the training course of field epidemiology for provincial, prefecture, and county staffs, and the training workshop for laboratory management skills. The related results of the present study are widely applied in these training activities. |
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