Analysis On The Development Issues Of Traditional Chinese Medicine Hospitals And The Responding Strategy

Objectives and Significances1. Comprehensive induction and systematic analysis on the policy of traditional Chinese medicine (TCM) is required for the evaluation on the TCM policyTraditional Chinese medicine (TCM) is the important component of health work in China, which has played an important role in protecting people’s health. Currently, due to the rapid development of economy and society and the resulting issues, TCM is in the negative and atrophic state, and is even alienated and marginalized. These have seriously limited the development of TCM and related industries. Four important meetings (1980s) have become the basis of the TCM development, providing the policy support to the rapid development and expansion of the TCM hospitals. In 1990s, TCM hospitals have put the hierarchical management system in practice, promoting the construction of the model TCM hospitals and forming the management mode of TCM hospitals with the standards-based management, goal-oriented management and regulation of hospital running. In 2009,’Construction and Development of Key TCM Hospitals Plan’ was adopted, which put forward to promote the heritage and innovation of TCM and achieve the revitalization and development of the pharmaceutical industry. May 2012, the State Drug Administration issued’China’s 12th Five-Year Plan on Pharmaceutical Industry’, proposed the specific targets for the construction of TCM hospitals in 2015. Therefore, the policy-orientation is the critical factor and the direction for TCM development.2. The development of TCM hospitals reflect the development reality and process of TCM undertakings and TCM policyThe TCM hospital is not only the executor implementing the development of TCM and the touch-stone of TCM development; but also the bridge towards the modernization and globalization of TCM. Therefore, the changes of development path and policy mode of TCM hospitals can profoundly reflect the trends, changes, problems, and the rise and fall of TCM development. It has the significance and realistic value for developing the effective strategic plan, setting the appropriate policies to safeguard the growth of TCM, promoting the development of national medical culture and serving the people’s health and national culture heritage.3. The understanding of the social environment and root of the TCM hospitals problems is the core of policy analysisThe health and social issues and the subsequent emerging medical problems, in the specific development stage of the recent three decades in China, are also inevitable in TCM hospitals. Numerous realistic issues in different stages of development and various effects arising from the policy orientation also occur and develop in the TCM hospitals and limit the development of TCM hospitals. Therefore, the TCM hospitals face not only the difficulties of inadequate investment and’drug-dependent hospital operation’, like which the general hospitals face; but also face special obstacles and bottlenecks in their own development. The dual pressures, arising in the historical development and in the realistic development process, are the important constraint to development of TCM undertakings and TCM hospitals. TCM hospitals face the development difficulties more complex than the general hospitals face.The existing research about the development of TCM hospitals paid main attention on the economic interests and benefits, investment costs and income, state subsidies and benefits, scale comparison between TCM and general hospitals, difficulties which TCM faced, and etc. Most of them were just the text description and phenomena analysis. However, lack of systematic evaluation and analysis on the problems in the TCM development, especially the key issues. To date, there is no long-term, multi-dimensional and overall study on the TCM policy after the China’s reform and opening to the world. So that, it is difficult to fully and accurately evaluate the TCM policy effects on the development of TCM hospitals. It will be the luxury for setting the high-value policies, which can contribute to the healthy development of TCM and solve the problems of TCM hospitals.Therefore, it is need to sort, analyze, compare, induce, summarize, and deeply research the impacts of policy context, economic and social development on the development of TCM undertakings. The comprehensive analysis on the existing problems, root and solving methods in the development process of TCM and TCM hospitals is the evidence and requirement for the future establishment of TCM policy.This study, based on the current survival and developmental status of TCM hospitals, with the starting point of the existing issues in the development process, is to deeply analyze the root of the problems. The development process and status of the related policy of TCM and TCM hospitals development are to be comprehensively summarized and analyzed. Using literature review, the problems and mechanisms in the development of TCM hospitals are systematically analyzed. Taking full advantage of the long-term survey data, the multi-dimensional demonstration and temporal trend analysis on the development problems and their root and mechanism in the TCM hospitals are executed, providing the important basic data and scientific evidence for setting the future policy.Materials and MethodsFirstly, using systematic review, the development context, process and status of TCM undertakings and TCM hospitals since the foundation of People’s Republic of China were summarized and sorted in the all-round way. The changes of TCM policy since the reform and opening up to the world were systematically analyzedFurthermore, under the guidance of the principle of the "Macro-Model of Health System", using literature review to systematically summarize and analyze the existing problems in the development of TCM and in the operation of TCM hospitals. Then the problems were sorted based on the importance and seriousness, in order to determine the focal problems.After that, the TCM hospitals and general hospitals of the 13 sample counties in three provinces (city) were investigated in several main aspects of the index including hospital size, operations, human resources, financial status and device configuration during 1995-2007. For each indicator, the change trends (vertical dimension) and comparison between TCM hospitals and general hospitals (horizontal dimension) were analyzed and evaluated, to further clarify and demonstrate the focal problems in the development process of TCM hospitals.Finally, combing with the intention survey, institutional survey and literature review, based on the compensation mechanism model of hospitals, the demonstration, severity, roots and mechanism of the determined focal problems were deeply analyzed, providing conclusive evidence for the focal problems and their roots and mechanism.Results1. The development process of TCM hospitals in ChinaDevelopment context and process of TCM hospitals.After the foundation of People’s Republic of China, TCM hospitals, from less to more, from small to large, with progressive development and steady improvement, have experienced three changes:from developing the coalition outpatient clinics by "discrete" individuals in TCM hospitals, to developing TCM outpatient department and TCM hospitals under different forms of ownership system; TCM hospitals, transferred to joint development between the TCM hospitals and TCM outpatient department from the "dominant" development of TCM hospitals; from the only emphasis on the expansion of TCM hospitals to paying more attention to special and functional effects. The development process of TCM hospitals can be divided into five periods:the initial establishment period, undergoing setback period, recovery period, scientific management period and market competition period.The policy changes of the development of TCM hospitals.With the important events in health system reform as the time node, the policy for the development of TCM hospitals in various stages in nearly 30 years were systematically analyzed. The results showed that the TCM policy development experienced five stages. Stage One (1979-1984):Using the economic instruments to manage health services; Stage Two (1985-1991):Expanding the hospital autonomy and fixing the quota for revenue and expenditure; Stage Three (1992-1999):Changing the operational mechanism and appropriately introducing the market mechanisms to accelerate the development of the hospital; Stage Four (2000-2008):Reform combing with the medical insurance, health care and medicine and strengthening community health services; Stage Five (since 2009):A new round of medical reform to promote and strengthen public hospital reform.The development changes of the TCM hospitals.The TCM institutions increased from 1,806 in 1987 to 39,305 in 2012, number of beds rose from 146,491 in 1987 to 613,582 in 2012; the number of TCM employees increased from 220,117 people in 1987 to 818,775 people in 2012. With the rapid development of TCM hospitals, the current macro policy induced the medical institutions to aspire after high-tech inspection and execute’drug dependent hospital operation’, in order to pursue their own survival and development. At this point, the TCM hospitals were obviously disadvantageous. The related policies for the TCM characteristics, limited to inherit and develop TCM undertakings, strengthen team building and TCM modernization, cannot resolve the problems in operating the TCM hospitals including the operating losses, loss of policy, development difficulties and other issues. In such circumstances, TCM hospitals had to gradually move toward the westernization and Western medicine road for their own survival.2. The problems in the development of TCM undertakings and the operation of TCM hospitalsThrough literature review, the problems existing in the development of TCM undertakings and TCM hospitals were defined, listed and summarized. Using different key words, various databases were searched, which covered all the health-related databases in China. Excluding the irrelevant literature and repetitive documents, a total of 348 literatures during 1982-2013 were obtained, with the wide range of representative. By rigorous literature review, various problems in the TCM development were analyzed and summarized. According to’Macro-Model of Health System’, which provided the’sub-mode, concept, index’ dimension, the problems were further evaluated and determined as 28 classes of major problems through saturation analysis. Based on the different levels of regions, fields and grades, the 28 classes of maj or problems were weighted and sorted by severity of the problem (mentioned frequency). The problems with priority ranking order in both seriousness and importance were determined as the focal problems:1) the unsound compensation mechanism for the TCM hospitals; 2) the high level and complete’Traditional Chinese Medicine Act’has not yet developed, the pharmaceutical industry relevant policies failed to consider TCM characteristics, and relevant standards need to be adjusted. These two focal problems were the macro policy causes and underlying mechanisms for the important phenomenon and issue of the "westernization trends" of TCM hospitals.3. The analysis on the key problems in the development of county TCM hospitals in ChinaWith the early accumulated data, using trend analysis and combining with the growth of local GDP, the changes in hospital size, human resources, operations, hospital finance, and equipment of county TCM hospitals during 1995-2007 were analyzed. The changing trends of the critical issues in the development of county TCM hospitals were investigated (vertical dimension). Meanwhile, this study also identify the development of county general hospitals, which were compared with the development of TCM hospitals (horizontal dimension), for further complete and clear revealing and determining essence of the problem in the development of TCM hospitals.The scale of the county TCM hospitals improved dramatically, but showed relatively shrinking, comparing to the county comprehensive hospitals.With the three-decades-efforts, the scale of county TCM hospitals significantly improved. The number of employees and the number of hospital beds doubled during 1995-2007, based on the substantial growth from the 1980s to the 1990s. The average fixed assets of TCM hospitals experienced more than 10-fold increase, and the increase rate of the assets was higher than the average growth rate of local GDP. Although absolute amount of the number of employees and fixed assets in TCM hospitals rose constantly, TCM hospitals actually showed relative decline trend, with respect to the development of the county general hospitals.The operation of county TCM hospitals significantly improved, but the provided services showed the homogenization trends with the general hospitals.The annual diagnose-and-treat person-times, outpatient person-times and inpatient-surgery person-times, the operational status indicators, of the county TCM hospitals increased significantly year after year. The annual diagnose-and-treat person-times, outpatient person-times and hospitalized-surgical person-times, the opera doubled and the annual inpatient-surgery person-times increased in more than three times, marking the improved treatment capacity in the county TCM hospitals after long-term support. The proportion of Western medicine inspection techniques in the operation of TCM hospitals experienced constantly increase, however the TCM diagnostic techniques weakened in TCM hospitals. County TCM hospitals were increasingly relying on the Western medicine technology; the westernization of the TCM hospitals has gradually become the trends.The human resource development in county TCM hospitals presented the westernization and westernization tendencies.The constitute of human resources in the county TCM hospitals represented significant improvement, achieving the leapfrog development of human resources in TCM hospitals.66% of the employees in the TCM hospitals have received junior college or higher education, indicating the significant improvement in the quality of the staffs in TCM hospitals. Both for the education levels of medical technicians and leading managers, TCM hospitals were lower than the general hospitals. The number of TCM medical technicians in county TCM hospitals increased year after year; however, its proportion in the total number of the employees showed decreasing trends. In 2007, only 22.6% of the total employees were TCM medical technicians, fell to the lowest level since 2000. With the shrinking of TCM medical technicians in county TCM hospitals, the medical technicians of Western medicine expanded constantly and more than 60% of the employees were medical technicians of Western medicine in 2007.The average annual income of county TCM hospitals increased, in which the drug income was the main source, and the ’drug dependent hospital operation’has become an important compensation mechanism for TCM hospitals.During 1995-2007, the annual income of county TCM hospitals increased from 13.68 million yuan to 80.77 million yuan in 2007, showing the six-times-increase of the absolute amount. Among them, the government’s financial allocation increased from the 7.24 million yuan in 1995 to 18.3 million yuan in 2007, but the percentage of financial allocation in the total revenue decreased from 52.9% in 1995 to 32.5% in 2007. The drug income rose from 382 million yuan in 1995 to 33.61 million yuan in 2007, an increase of nearly 10 times. Since 2000, the proportion of drug income in the total income had exceed that of financial allocations, up to 36.2% and proportion of drug income has accounted for 41.6% of total financial income in 2007.The proportion of income of Western pharmaceuticals in the whole drug income increased, indicating the obvious westernization trends.During 1995-2007, the proportion of the income of Western Pharmaceuticals in the drug income composition further increased, which increased from 61.3% in 1995 to 80.1% in 2007, an increase margin of nearly 20%. The revenue of proprietary Chinese medicines and Chinese herbal medicine, previously were the main use in TCM hospitals, continued to shrink, dropping from 15.8% in the mid-90s to 4.1% in 2007. It was difficult to sustain the TCM hospitals relying on their own traditional medicines. The annually decreased treatment rate of TCM showed the gradual loss of the TCM characteristics.The overall level of equipped instrument in TCM hospitals enhanced and reached the same level of the general hospitals; but highly repeated that of general hospitals, indicating the westernization trends in instrument.During 1995-2007, the county TCM hospitals experienced the rapid increase in instruments and equipment. The average number of instruments with the price more than 10 thousand yuan soared from 7.6 units in 1995 to 46.2 units in 2007, an increase of more than 6 times. The ratio of the number of the instruments with the price more than 10 thousand yuan purchased by the TCM hospitals to the general hospitals increased from 76.0% in 1995 to 96.3% in 2007, indicating that the instrument equipped in the county TCM hospitals has reached the similar or the same level to the scale of the county general hospitals. Despite the substantial increase in the equipment in the TCM hospitals, the purchased instruments in TCM hospitals showed high repetition to that in general hospitals, especially the higher repetition in the treatment equipment. The constant rise of the rate of use time, the daily diagnose-and-treat person-times and the weekly diagnose-and-treat person-times per thousand yuan investment of the treatment instruments in TCM hospitals indicated the continuous convergence between the treatment technics of current TCM hospitals and that of the general hospitals. The treatment technics of current TCM hospitals increasingly relied on Western medicine treatment equipment.4. The analysis on the root of the focal problems and the establishment of the responding strategyThe organizer and implementers of the TCM services highly recognized that the development of TCM hospitals depended on the national policy.If it is difficult to guarantee the finical investment, the county TCM hospitals will face greater difficulties. This dilemma in the development of TCM hospitals seriously hampered the development of TCM hospitals and even the development of TCM undertakings.The westernization trends of the TCM hospitals have become the important realistic issues.Compared with the 1990s, in the TCM hospitals, the following issues in current TCM hospitals are more prevalent, including:1) the consumption of drugs are mainly in Western Pharmaceuticals; 2) the TCM hospitals blindly purchase the medical devices which enhance the diagnostic capabilities of Western medicine; 3) attitude of the medical technicians are negative on the status of TCM hospitals; etc. The westernization tendencies of TCM hospitals have not only become the prevalent and conspicuous realistic issues, but also the focal problems in the development process of the TCM hospitals, which were generally concerned and highly recognized by the medicine services, providers and consumers.The compensation approach is the important mechanism and the TCM policy failed to consider the features of TCM is the critical macro policy root for the westernization of TCM hospitals.Most respondents believe that the current government financial input for the TCM hospitals is inadequate and the pricing of medical services is unreasonable, resulting in the challenges for the county TCM hospitals to maintain the functional operation and personnel expenses. The lack of competitiveness of the county TCM hospitals in competing with the general hospitals induced more difficulties for the TCM hospitals to survive as the economic entity. This study found that for this problem, all the parties have the high recognition rates, in which the county TCM hospitals have the highest recognition rate up to 93.4% and the health administrative departments also have the relatively high recognition rate as 85.2%. Compared with the 1990s, the recognition rate in 2000 increased significantly. With the shrinking of the financial investment from the country, due to the homogenization between the TCM and Western medicine policy, the TCM hospitals, like the general hospitals, transferred the compensation approach and to seek the Western-medicine-style service approach, especially the service items which can increase the income. These have increased the westernization tendencies of the TCM hospitals, to which the parties have the high recognition rates which was higher after 2000.Main Explorations and Innovations in the StudyUsing the scientific policy-making procedures, the macro model of health system, multi-dimensional combined evaluation method, qualitative and quantitative multiple demonstration and analysis on the root and mechanism of the focal problems, etc., focus multiple causes and mechanism analysis and other methods, the ideas, steps and methodology, for analyzing the development issues of the TCM undertakings and TCM hospitals and setting the responding strategy, were formed and developed. They are scientific, available and feasible, confirmed by the field survey results and multiple demonstrations.This is the first time to systematically analyze the development path of the TCM undertakings and TCM hospitals since the founding of the People’s Republic of China; and to comprehensively summarize and clarify the change process and development context of the TCM hospitals since the reform and open to the world, providing the scientific evidence for the long-term and large-scale understanding the development of the TCM undertakings, TCM policy and TCM hospitals and development issues.Comprehensively using literature review, expert consultation, institutional surveys and intentions surveys, and establishment surveys and intentions surveys, the development problems of TCM hospitals were defined and demonstrated. Through the multiple demonstration process of "theory-survey-theory-survey", the focal problems and relevant root and mechanism in the development of TCM hospitals were identified.Based on the idea and method of horizontal and vertical comparison, the temporal trends of the development of the county TCM hospitals during 1995-2007 were analyzed, which were compared to that of the general hospitals in the same period, further revealing the common and special development problems of TCM hospitals.