Construction And Application Of Evaluating Index System For Fairness Of Primary Health Care Services In The Background Of Tiered Medical Services System

Objective:Raising the equity of primary health care services is not only an important basis for improving the tiered medical services system in China at the current stage,but also an important part of strengthening the construction of primary health care services.In this study,with the background of tiered medical services,the temporal and longitudinal changes of China's primary health care services before and after the implementation of the tiered medical services system and the present situation of horizontal distribution of primary health care services were analyzed.Afterwards,Delphi expert consultation was used to construct an evaluating index system for fairness of primary health care services in urban areas,and an empirical study was conducted using this index system.Nanjing,the provincial capital of Jiangsu Province,was selected as the research object to evaluate the status quo of its primary health care services.The effectiveness and operability of the constructed index system were tested to provide a theoretical basis for assessing and comparing the fairness of primary health care services in other regions.It also proposes effective suggestions for Nanjing and Jiangsu Province to continue to deepen tiered medical services system and improve the fairness of primary health care services.Methods:(1)Delphi expert consultation is used to construct an evaluation index system.The mean,standard deviation,coefficient of variation,and comprehensive coefficient of each index are calculated according to the scores of experts.The indexes are eliminated according to the criteria where the comprehensive coefficient is less than 7.5,and the contents of the indexes were deleted and improved according to expert opinions.After two rounds of expert consultations,the evaluating index system was constructed.The reliability of the consultation results was analyzed using SPSS22.0 and R software and the weights,connotations,and evaluations of each index were determined by combining the fuzzy comprehensive evaluation method and the comprehensive scoring method.(2)Designing a questionnaire based on the constructed index system and taking Nanjing as an example to carry out empirical investigations.Investigations and questionnaires were conducted on 15 community health service centers in Nanjing and 486 residents in their jurisdictions.SPSS 22.0 was used to collate the survey data,and the Cronbach's a and factor analysis methods were used to perform intrinsic reliability test and construct validity test on the residents' survey targets.(3)The scores of each administrative district of Nanjing in the fairness evaluation dimensions are calculated according to the results of the empirical investigation,combining the indexing scheme of each index in the evaluation system of the fairness of the primary health care services.Weighted by the proportion of population in each administrative district of Nanjing,using Excel 2010 to draw the Lorenz curve,calculate the Gini coefficient and Theil index,and evaluate the fairness of primary health care services in Nanjing according to the calculation results.Results:(1)After two rounds of expert consultation,an evaluating index system for fairness of primary health care services was established.The reliability analysis of the consultation result shows that the positive coefficient and the authoritative coefficient of the two rounds of Delphi expert consultation met the requirements,the second round of the Kendall coefficient was close to 0.5 and the P value was less than 0.001.It can be considered that the consultation results are highly reliable.(2)The Cronbach's a and the total Cronbach's a of each dimension included in the correlation evaluation index in the reliability test result are all greater than 0.8,indicating that the evaluation index has good internal reliability.The KMO value of the correlation evaluation index in the validity test was 0.895,and the P value of Bartelett's ball test was less than 0.001,indicating that the index was suitable for factor analysis.Three common factors were extracted in the factor analysis,and they respectively explained 66.938%connotation of evaluation indicators from the three dimensions of supply,utilization,and fairness of results,and the load values of all indicator factors are also greater than 0.5,which further validates the validity and reliability of the basic health care service evaluation index system in terms of content and structure.(3)The fairness evaluation result shows that the equity of the primary health care service in Nanjing is highly equitable in terms of funding dimension,resource allocation dimension,supply dimension,and outcome dimension.However,the fairness of use dimension is poor,its Gini coefficient is 0.2636,and its total Theil index is 0.0930,which reveals that the fairness of the use of primary health care services in Nanjing should be improved in the future.Conclusion:(1)The Delphi expert consultation was used to construct the evaluating index system for fairness of primary health care services applicable to urban areas.The reliability and validity test shows that the reliability and validity of the related index systems were all good,and the empirical analysis process also indicates that the indicators in the actual use of the process has a high degree of operability.(2)The empirical research result shows the equity of the primary health care service in Nanjing is basically in a high degree of fairness,and the fairness differences among the three major blocks in the old city,new city,and suburbs of Nanjing are not obvious,however,there is still a gap in the level of fairness among different administrative regions.In the future,the government should continue to improve the fairness of each dimension of primary health care services in Nanjing by improving the financial allocation mechanism,rationally planning the allocation of resources between various administrative regions,intensifying the implementation of policies concerning hierarchical diagnosis and treatment,improving policy guidance and payment methods,and improving overall service capabilities.