Study On The Purchasing Strategies Of Basic Health Care In Rural Areas

Background"Equitable and universal access to basic health care for all" is established as the strategic goal of the new health reform plan in China. The Basic health care sector, comprising public health care and basic medical care, is regarded as the foundation as well as the core of the whole health system. The equity, efficiency and quality of the basic health care sector is closely linked to the population's health and welfare, and also count for the optimization of the performance of the health system.Rural health is the key of the health system in China. However, the basic health care and its delivery system, the township health center and village clinics, in rural area suffered inadequate funding for a long time. More seriously, the invested funds were not effectively and efficiently used. Market failure and government failure prevailed in the health sector, while the irrational use of health resources, the unreasonable health demands as well as the perverse incentives made things worse that resulted in inefficiency, low quality of basic health care and waste of resources. Therefore, the effective strategies to promote the access and to enhance equity, efficiency and quality of the basic health care must be sought along with the fund increases to drive the health system change well and improve the health outcomes of the rural population.In China, the primary health facilities and its provided services are funded through two main channels:government fund and health insurance fund. Generally, the public fund goes in two ways:one is direct subsidies or budgets to the public facilities, the other is an independent purchasing role buy the health services for all or specific population. Recently, there is a common trend in health sector reform worldwide, which is a move from hierarchical and integrated forms of service delivery and finance towards devolved models based upon the separation of the responsibility for purchasing services from the responsibility for providing them. However, the passive exercise of purchasing that involves mere post-reimbursement of expenses to providers is far from enough. Hence, the strategic purchasing based on purchaser-provider split is promoted as a key policy instrument to improve health system performance and becomes a heated topic for research and practice around the world. The priority of health care reform agenda is "to ensure basic health care, to strengthen primary health facilities and to establish mechanisms to achieve the goal", with the idea of purchaser-provider split and strategic purchasing written in the reform plan. However, the practice of purchasing of basic health care, particularly in rural areas, is in its very first stage while the study on purchasing is still in the initial process of introduction of concepts. There are limited researches on the status quo of purchasing system, design of purchasing strategies, say nothing of the evaluation of purchasing interventions in China. Thus in the context of the new health care reform, it is essential to conduct studies on purchasing system of basic health care, especially in rural areas, to develop the purchasing strategies on what to buy, how to pay and from whom to buy to achieve rational use of resources and effective motivation for providers in the condition of limited competition and low capability of providers, making the full use of the government fund and the medical insurance fund to fulfill the ultimate goal of health system.ObjectivesUsing normative study to understand the relationships between different actors in health care purchasing system and the interactive mechanisms among the relationships, based on which the approach framework to design and develop purchasing strategies is established. Applying theories into practice through case study:to diagnose the main problems of basic health care system performance in rural areas and find the root courses from the perspective of purchasing, to design series of purchasing strategies, especially the payment methods and then monitor and evaluate the purchasing interventions after implementation.MethodsEmploy three theoretical frameworks. The policy cycle framework was adopted as the general approach of the research, starting from the problem definition, through diagnosing, design, political decision, implementation and ending with evaluation; the development and reform framework was used as the method to find the causes of the problems and to develop the design approach framework of the purchasing strategies; the result chain framework was taken to guide the monitoring and evaluation of the purchasing interventions.Case study was conducted to make application of theories and rationales. Rural area in the Ningxia Hui Autonomous Region was selected as a case for its representativeness and reform foundation in advance. Two counties in Ningxia (Haiyuan and Yanchi) were investigated in detail, and then the design, monitoring and evaluation of the strategic purchasing policies are developed accordingly.Some investigation methods were used. Literature review was applied to realize the rationales and practices of health care purchasing home and abroad and the secondhand data of system performance before and after intervention; household survey and facility survey were conducted in February 2009 to attain the information about health care demand and utilization of the population as well as situations of the primary facilities, health workers and health care operations; qualitative interviews were intended to know about problems and reasons, stakeholders'appeals and their views and appraisals after interventions implementation.Furthermore, PETS analysis and difference-in difference method were driven to verify feasibility and evaluate the effect and impact of the interventions respectively.Results1. Summary of rationales and practices of strategic purchasing:Aimed at improving the health system performance, strategic purchasing involved the realization of public's health need, emphasis on cost-effective services, reconstruction of incentives for providers, encouragement in competition and requirement of government stewardship. Proactive decisions were made about which health care services should be purchased, how and from whom. There were at least four roles and three principal-agent relationships inside the purchasing systems:the purchaser acted as the consumers'agent in the purchase of health care services on their behalf; the purchaser employed a providers to deliver the appropriate mix of health care, of acceptable quality, at an agreed price; the purchaser acted as agent for the government or state to rationally allocate health resources. In order to make the agent acts well, series of tools and mechanisms must be adopted to ensure the relationships.2. Combining the purchasing theories with the health system model to produce the approach framework for developing heath care purchasing strategies:Purchasing strategies comprised the "core policies" deciding which interventions should be purchased, how they should be purchased and from whom from the purchaser's standpoint as well as the "supporting and ensuring policies" mainly aiming at the organization and institution environment from the perspective of the health system. According to the health development and reform framework, instruments towards the financing, payment and part of the organization knobs could be used to establish the core policies of purchasing primarily acting on the relationship between purchaser and provider; other organizational, regulation and behavioral instruments were proposed to work as the supporting and ensuring policies.3. Applying theories on empirical case to define and diagnose basic health care problems in rural area:public health care and basic medical care are the key points for rural population's health need, however empirical data showed that the accessibility, efficiency and quality of basic health care were low while the primary health facilities, particularly the village clinics were incapable and short of supply. Purchaser-provider split already existed in the system; however, the purchasing was in a passive form. The main reasons for the problems were the inappropriate mix of core purchasing policies, and the root courses were based on the purchaser's insufficient representativeness for the population, poor mechanisms for the purchaser to control providers and limited stewardship of the government.4. According to the approach framework for developing heath care purchasing strategies to design the improved purchasing strategies for the rural area:core policies implemented by the purchasers (the local government, the health department and the NCMS office) including financial strategies to integrate public health care fund with NCMS fund, adjust the scope and reimbursement rate of benefit package; payment strategies to change the payment method, enhance provider's income and pay for performance; organizational strategies which were derived from the payment strategies to integrate the township and village delivery system and to introduce competition. Besides, defining the roles of the township and village providers, establishing mechanisms for the residents to participate and monitor the purchasing processes, launching health education as well as training to promote the specialty and management competence of providers were projected to act as the supporting and ensuring policies. 5. Developing the payment methods as core mechanism in details:blended payment methods acted on the entire township (including the township health center and all the village clinics) were taken to trade off the multiple objectives of the basic health care, prepaid capitation of the public health care and basic outpatient care targeting efficiency, fee-for-service of medical fee per visit enhancing accessibility, and pay-for-performance of the reserved 30% budget improving service quality. Based on the design, integration of township health center and village clinics and competition may emerge in the context of changed incentives, further optimize the resource allocation. A model of the mechanism of action of the financial incentives among the payment methods was produced and accordingly, financial incentives have to be cooperated and promoted mutually with other regulation and management tools. So MIS, protocols, monitoring and quality assurance system and the internal management of providers must be well developed.6. Monitoring and evaluating the purchasing interventions with the guide of results chain:the designed strategies have been implemented in the two pilot counties, mainly focused on the adjustment of benefit package and reform of payment system in the first phase. Though the pilot was still in its initial stage and there was lack of clear and definite evidences of the effects and impacts, some positive phenomenon were witnessed:intended behavioral changes of providers and demanders appeared, utilization of outpatient services in primary facilities increased rapidly and dramatically, efficiency of resource use was seen improved. Thus the progress of the project was in line.Suggestions1. To introduce "strategic purchasing" when public fund is invested into the health care in rural areas to improve the system performance.2. To adjust the benefit package to fulfill populations'needs for preventive health care and medical care of common diseases and chronic diseases.3. To integrate the public health care fund and basic medical care fund (usually NCMS fund) sources together to enhance purchaser's power over providers. 4. To adopt blended payment methods to balance the multiple goals of health care to achieve accessibility, equity, efficiency and quality. Change the payment to primary health facilities for basic health care form pure fee-for-service method to combined capitation, fee-for-service and pay-for-performance.5. To offer proper level of income, rational definition of the provider role, reasonable norms and protocols and intense trainings to providers to solve the problem of insufficient human resources and low productivity.6. To make use of financial incentive structures to promote the integration of township and village providers, for example, the township health center is permitted to share the village clinic's residual or takes responsibility of the performance of the latter which is also related to its own revenue.7. To establish the population participation mechanism such as citizens'juries or purchasing boards to improve the agency function of the purchaser.8. To devolve the right of decision making and action towards lower-level, such as local government and local medical insurance organization, while the purchasers strengthen their capacity and credibility to reinforce the reactiveness of purchasing.9. To persist in government's domination in the purchasing through stewardship and scrutiny and preserve government funding in the infrastructures and human resources of the public providers.10. To lay great efforts on construction of management information system to support the process of purchasing and to integrate other management and regulations such as provider positioning, clinical guidelines constitution, increasing provider capability and autonomy, provider ethics training and demander health education, with the core purchasing strategies.11. To carry out rigorous and comprehensive monitoring and evaluation of the designed interventions involved in this research and so is for other purchasing programs. SummaryThis study introduced the concept of strategic purchasing of health care for the first time. Based on the summary of purchasing theories and the model of health system, an approach framework for designing and developing purchasing strategies was established. Then theories and the conceptual framework were put into practice through a case study. The problems of the health system in Ningxia rural area was defined and diagnosed form the purchasing perspective, the concrete purchasing strategies and policies were then developed and the results were validated in the real world. The idea of strategic purchasing, the approach to produce purchasing strategies and the specific purchasing strategies and payment methods developed in this study can be learned, extended and generalized, as a demonstration for other places, the western rural areas in particular.