| Objectives:As the basis of health service system, primary health institutions (PHIs), including the community health service center and the rural township health center, are the major providers for basic medical service and essential public health service in China. And quality and efficiency of the service have great effect on the utilization of primary health service and the efficiency of the whole service system. Since the launch of the new health care reform in 2009, the government has made great efforts in increasing financial supports for PHIs, and county level authorities have been conducting performance management (PM) pilot projects at the same time, which aim to improve the performance of PHIs. However, the experience of some domestic projects suggested that the operation/management cost of PM were relatively high and PHIs need to complete lots of extra work, which even affected the service provision. Therefore, this paper tried to estimate the cost of the PHIs and the improvement of performance they gained after participating in PM. In addition, the incremental cost-effectiveness ratios of PHIs (ICER) were also estimated to make comparisons between different institutions, which would help to find the influencing factors on the efficiency of performance improving activities and provide reference for the government in the expansion of PM projects.Methods:Qualitative and quantitative studies were conducted in 18 PHIs in Jieshou, Anhui. Qualitative data were obtain from a forum with 16 presidents of these PHIs and in-depth interviews with four township center hospital presidents, from which we can finish the job analysis of PM. Quantitative data was obtained from the financial statements in 2013 and 2014 from Health Bureau; performance survey with 12 KPIs including financial status, medical service and public health service provision; costs survey that collected the incremental costs consumed in different workflow of PM. We used Activity-Based Costing in cost accumulation and measurement, quantified the hidden costs of PM using Fuzzy Comprehensive Evaluation Method, evaluated the implementation effect of PM with Composite Index Method. Besides, we estimated the ICERs of 18 PHIs after participating in PM and explored the obstacles and reasons that PHIs met with in performance improving with Archetype Analysis Method.Results:(1) the incremental costs was 0.387 million CNY for each PHI (0.138 million of financial costs and 0.249 million of manpower cost). Almost 86% of manpower cost was spent on the work of feedback and performance improvements, while 91.3% of financial costs were spent on the construction of the hospital environment and the purchase of medical equipments. The financial costs takes up 2.56% of the total annual expenditure of PHI. (2) Although PM indeed increased the work pressure/load of employees, it also helped to improve the management efficiency, attitude for working, institution’s reputation, etc... And quantitative analysis shows that these hidden costs helped to increase the total income by 0.68 million which was much higher than the sum of financial cost and manpower cost. (3) PM in Jieshou was not conducted in accordance with provision, which is supposed to promote continuing improvement of overall performance but not just performance of the essential public health service. Nonetheless, the average performance index of these 18 PHIs have increased by 11 compared to what they were in 2013, while two PHIs (A06, C1) decreased by 9 and 0.35. Correlative analysis showed that there was a positive correlation between performance index in 2014 and changes in performance ranking (Pearson correlation:P=0.002, R=0.680; Spearman correlation: p=0.005, r=0.626), which indicated that 18 PHIs have potential to improve performance without plateau. (4) Incremental cost efficiency analysis suggested that an additional 36,000 CNY (13,000CNY for financial costs and 23,200 for manpower cost)was needed for index to increase by 1 on average. And ICERs for general township hospitals and those PHIs with fewer employees and worse financial status tend to be higher than their counterparts. (5) Archetype analysis showed that incoordination between health facilities and health personnel constrained the performance growth; efficiency of PHIs were associated with the limited number of available employees in PHIs, heavy tasks of essential public health service tasks and the limited capacity of clinics; with serious variation in financial status, some PHIs failed to invest in the health facilities and employee education, which would lead to the difference in performance improvement.Policy suggestions:(1) optimizing the PM model to improve the performance of medical service and public health service, innovating the performance assessment method to improve the efficiency of PM, such as strengthening the information construction of PHIs; (2) improving the financial incentive and non-financial incentive of employees in PHIs to improve the service capability and reduce the rate of brain drain; (3) strengthening the government’s financial support for the development of basic construction of PHIs and try to take on all the cost of reasonable performance improvement activities; (4) Health Bureaus are supposed to achieve balanced development of essential public health service and basic medical service with PM, and provide policy support to service provision and utilization that PHIs provided. Managers of PHIs also need to try their best in the development of the institions and the increase in the efficiency of PHIs. |
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