Model to assess workload of village doctors in the National E sential Public Health Services Program in six provinces of China

doi:10.21203/rs.3.rs-19755/v1

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Model to assess workload of village doctors in the National E sential Public Health Services Program in six provinces of China

https://doi.org/10.21203/rs.3.rs-19755/v1

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published 09 Dec, 2020

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Background: Village doctors face many challenges in providing the National Essential Public Health Service (NEPHS) program, and many factors affect the provision of these services. However, there are no studies (particularly quantitative analyses) regarding the workload of public health services provided by village doctors. In this study, we aimed to develop a quantitative analysis approach to measure the workload of NEPHS provided by village doctors in six provinces of China in 2016. Methods: Based on survey data from 300 town hospital centers (THCs) located in 60 counties in the six selected provinces, we calculated village doctors’ share of workload under the NEPHS using the equivalent value (EV) model. To define the workload and corresponding EV of each NEPHS, a series of five meetings was held with THC managers, public health workers, family physicians, nurses and village doctors. Field observations were conducted to verify the workload and EV of each service.

Results: Village doctors’ share of the workload under the NEPHS program was 47.0% across the 300 sampled THCs in six provinces. The village doctors’ workload shares for different NEPHS ranged from 17.1% to 57.0%. The percentage workload undertaken by village doctors under the NEPHS program varied across different provinces, with the highest proportion 63.4% and the lowest 28.5%. Conclusions: The total NEPHS workload assigned to village doctors by THCs in the six sampled provinces exceeded the Chinese government’s requirement of 40%, but the workload proportion in some provinces was less than 40%. We suggest that local governments conduct district-level analysis of the workload among village doctors under the NEPHS program using the EV method, to identify priorities and influencing factors and implement targeted measures to promote health service provision. An EV model of the NEPHS could be built to monitor village doctors’ workload and ensure that assigned workloads are manageable.

Health Economics & Outcomes Research

Health Policy

Workload

Village doctors

National Essential Public Health Services program

Equivalent value

Recent decades have witnessed rapid improvement in China’s public health system, with average life expectancy up from 71.4 to 74.8 years between 2000 and 2010 [1–2], the maternal mortality rate down from 51.3 to 26.1 per 100,000 population and the infant mortality rate dropping from 29.2 to 12.1 per 1,000 live births between 2002 and 2011 [3–5]. Despite this progress, diseases including hypertension, obesity, diabetes and other non-communicable diseases still pose challenges to China’s public health [6, 7]. To tackle these issues and rid patients of unnecessary and costly secondary and tertiary care, early prevention and intervention programs have been in place since 2009. One of these, called the National Essential Public Health Services (NEPHS) program, is intended to provide equal access to public health services regardless of geographic location and to expand the coverage of essential public health services to all Chinese residents [8]. The NEPHS program aims to narrow the gap between rural and urban residents with respect to essential public health services and to ensure equity of access to these services [9]. Since the NEPHS program was launched 10 years ago, the types of services included in this program have progressively increased, from nine in 2009 to 12 in 2016. The allowance standard per capita for the program has increased from 15 RMB in 2009 to 50 RMB in 2016. The 12 types of public health services mainly target children aged 0–6 years, pregnant women, those aged over 65 and patients with mental health issues and chronic conditions [10–11]. Services are offered through community-based primary health care facilities [9]. These are universally accessible and cover town hospital centers (THCs) and village clinics serving 589.7 million residents in rural areas of China as well as community health service facilities that served 793.0 million residents in urban areas in 2016 [12].

In rural China, health services are provided by a three-tiered system of county hospitals, THCs and village clinics [13]. As the basis of health service networks in rural areas, village doctors currently serve nearly half the population of China (42.6%). Before the start of the NEPHS program, there were 864,000 village doctors working in 583,000 village clinics in 2005. By the end of 2016, 639,000 village clinics had been set up in 560,000 administrative villages across China. In total, there are 1,436,000 staff members in these village clinics, including 320,000 practicing (assistant) physicians and 933,000 village doctors. The number of consultations offered by village doctors and practicing (assistant) physicians in 2016 reached 1.85 billion, 2.57 times that of consultations provided to urban residents by practitioners working in community health service facilities (0.72 billion) [14]. The number of residents served by one village doctor varies with the number of doctors in the village. On average, one village doctor might provide primary health care for 1000–2000 rural residents [14].

It is mandatory for township hospital centers (THCs) and village clinics to provide NEPHS to rural residents [15]. Central and local governments are responsible for subsidizing village doctors for providing these services [16]. The willingness of village doctors and THC managers to provide NEPHS is relatively high because of the introduction of a minimum subsidy [12]. The NEPHS program allowance makes up the largest proportion of village doctors’ income throughout most of rural China [12, 17]. In an effort to reasonably distribute the total workload among THCs and village clinics, the government also transfers, in principle, around 40% of the NEPHS workload to village doctors via the program allowance in the form of government service purchases based on performance assessment [18]. Funds are paid to the THCs and allocated by the THCs to village doctors and THCs. The distribution is based on the estimate of village doctors’ performance generally including work volume, quality and residents’ satisfaction with NEPHS [12]. THCs might impose an economic penalty on village doctors for work that is poor or unfinished [15, 19].

Village doctors have an increasingly important role in the provision of NEPHS in rural China [19–20]. The government has attached great importance to facilitating the provision of a greater quantity and higher quality of NEPHS by village doctors, which not only helps to improve the accessibility to public health services in rural areas but also stabilizes teams of village doctors [20]. In recent years, several qualitative studies have been carried out on the provision of NEPHS by village doctors [12, 19–22]. The study findings show that these doctors face many challenges in providing NEPHS and many factors affect the provision of health services. Some factors like village doctors’ age, sex (in most districts of China, male village doctors do not provide maternal health services to women), or poor level of education are difficult to change whereas others can be improved, such as lack of effective incentives, poor computer skills, inadequate professional NEPHS training, insufficient equipment allocation and lack of cooperation from rural residents [12, 22]. However, there are no studies (particularly quantitative analyses) on the public health service workload of village doctors and differences in service delivery by village doctors according to region and services. The present analysis can provide a more comprehensive perspective on the provision of public health services in rural areas by village doctors. We used a quantitative analysis approach to measure the NEPHS workload of village doctors in 300 THCs in 60 counties of six provinces in China. Our findings could provide governments at all levels with a reference point and basis for promoting NEPHS provision and formulating relevant policies.

2.1 Sampling

In this study, we adopted a random cluster sampling method. Zhejiang, Fujian, Anhui, Hunan, Yunnan and Shanxi provinces were selected for this survey. In each province, we chose five prefecture-level cities at random and in each prefecture-level city, we randomly selected two counties. Five THCs were randomly chosen from each county. In total, 300 THCs from six provinces were surveyed. On average, each THC has 40 on-duty staff, 34 health care specialists, 16 doctors and 5 certified (assistant) doctors, with an average of 37,270 outpatient and emergency visits plus 1,344 inpatients per year. An average of 20 administrative villages and 16 village clinics are under the governance of each THC. Each village clinic is staffed by 1.3 health care professionals.

2.2 Data collection

Using the NEPHS guidelines for 2011, the research team designed questionnaires and survey instructions. Survey questions covered basic information of the sampled THCs and statistics of the total workload assigned according to the 12 types of services and the share of workload undertaken by village doctors in village clinics. The share of workload undertaken by village doctors in village clinics was estimated and reported separately by each service-related department in THCs according to the actual workload carried out by village doctors. The survey tool was pre-tested in two THCs of Beijing and further revised. Before conducting the survey, the research team confirmed the list of sample provinces, cities and counties. To guarantee a high response rate, the Primary Health Department of the National Health and Family Planning Commission issued a notice regarding the survey. Provincial health and family planning administrative departments in the sample provinces organized sample counties and selected sample THCs, as required, checking whether all answers on the questionnaires had been completed and reviewing the data for accuracy. After receiving the questionnaires, the research team rechecked everything and carried out logic checks. During the survey, the research team provided advice by telephone and kept records.

2.3 Model

The equivalent value (EV) method has been used to estimate the cost of the NEPHS program and to calculate community health-staffing requirements [23–27]. In the present study, we used the EV method to build a model for measuring the workload of NEPHS provided by village doctors, according to the following steps: 1) determine the standard service protocol of all types of NEPHS; 2) determine the workload and EV of each NEPHS compared with a standard clinic visit; 3) calculate the village doctors’ workload in the NEPHS program.

Step 1: Determining the standard service protocol

In 2016, the NEPHS program had 12 types of public health services. These included establishing health records for residents; management of patients with chronic non-communicable diseases; physical examination for major diseases in children, women and older people; health education; vaccination services for vaccine-preventable diseases and prevention and control of major infectious diseases. All 12 types of NEPHS are included in the 2011 NEPHS guidelines [11].

Step 2: Determining the workload and EV of each NEPHS

To determine workload (person-time), we used a multistage iterative feedback and revision process [26–28]. Participants (n = 60) from the six sampled provinces were invited to attend a series of five meetings according to their expertise with NEPHS. Participants included THC managers (n = 12), public health workers (n = 12), family physicians (n = 12), nurses (n = 12) and village doctors (n = 12). During the meetings, participants discussed the amount of person-time required for each NEPHS, according to the 2011 NEPHS guidelines. Participants also suggested modifications to the workload indicators. As the population density and delivery models differed in eastern, central and western areas of China, two sets of specific workload were created for each NEPHS.

To test the workload of each NEPHS, four research assistants were trained to observe and record the person-time for each type of service in 12 THCs randomly chosen from the six sampled provinces. In terms of services that could not be recorded during direct observation, face-to face interviews with public health workers were conducted to determine their workload. The person-time for each NEPHS was rechecked and modified on the basis of direct observation and interviews.

To ensure that different public health services could be compared directly, a “standard clinic visit” was introduced as a benchmark to gauge the EV for NEPHS [23–28]. A standard clinic visit referred to a family physician consulting with one patient for 15 minutes [29] and the EV of a standard clinic visit was defined as 1. The EV of each NEPHS was then determined based on the person-time compared with a standard clinic visit. The workload and EV of each NEPHS in different areas was defined separately and is shown in Table 1.

Table 1

Workload and EV of each NEPHS in different areas (compared with a standard clinic visit)
Types	Service Contents	Unit	Mid-east China*		Western China
Types	Service Contents	Unit	Workload(minutes)	Mean EV	Workload(minutes)	Mean EV
Standard clinic visit	Family physician consulting with patient	per person	15.0	1.0	15.0	1.0
Health records management service	Establish residents' health records	per person	30.0	2.0	37.5	2.5
Health records management service	Update of residents' health records	per person	7.5	0.5	12.0	0.8
Health education	Make annual implementation plan of health education	per time	720.0	48.0	1170.0	78.0
	Set up health education bulletin board	per time	373.5	24.9	720.0	48.0
	Public health consultation activities	per time	669.0	44.6	135.0	9.0
	Public health knowledge lecture	per time	463.5	30.9	480.0	32.0
Immunizations	Establish vaccination file	per person	9.0	0.6	10.5	0.7
	Vaccination service	per visit	16.5	1.1	16.5	1.1
	Handling of suspected abnormal vaccination reaction	per visit	18.0	1.2	6.0	0.4
Health services for children aged 0 to 6 years	Family visit of newborn	per visit	118.5	7.9	52.5	3.5
	42 days follow-up	per visit	72.0	4.8	51.0	3.4
	Infant physical examination	per visit	30.0	2.0	16.5	1.1
	Physical examination of preschool children	per visit	30.0	2.0	69.0	4.6
Maternal health services	Early pregnancy health management	per visit	54.0	3.6	37.5	2.5
	Health management in the second trimester	per visit	40.5	2.7	27.0	1.8
	Health management in late pregnancy	per visit	42.0	2.8	27.0	1.8
	Postpartum visit	per visit	81.0	5.4	30.0	2.0
	42 days postpartum health examination	per visit	42.0	2.8	28.5	1.9
Elderly people’s health services	Physical examination for the elderly	per person	39.0	2.6	34.5	2.3
Elderly people’s health services	Health guidance for the elderly	per person	12.0	0.8	6.0	0.4
Health services for patients with hypertension	Screening of patients with hypertension	per person	39.0	2.6	24.0	1.6
	Follow up evaluation and classified intervention of hypertension patients	per visit	36.0	2.4	36.0	2.4
	Health examination for patients with hypertension	per person	42.0	2.8	34.5	2.3
Health services for patients with type II diabetes	Diabetes screening	per person	42.0	2.8	31.5	2.1
	Follow up evaluation and classified intervention of diabetic patients	per visit	36.0	2.4	37.5	2.5
	Physical examination of diabetic patients	per person	42.0	2.8	37.5	2.5
Health services for patients with severe mental illness	Information management of patients with severe mental illness	per person	108.0	7.2	79.5	5.3
	Follow up evaluation and classified intervention of severe mental illness	per visit	72.0	4.8	42.0	2.8
	Physical examination for severe mental illness	per person	66.0	4.4	43.5	2.9
Reporting and management of infectious diseases and public health emergencies	Discovery and registration of infectious diseases and public health emergencies	per time	114	7.6	21.0	1.4
	Report and handling report of infectious diseases and public health emergencies	per time	121.5	8.1	7.5	0.5
Health management with Chinese medicine	Recognition of TCM constitution (aged over 65)	per visit	30.0	2.0	27.0	1.8
	Health care guidance of traditional Chinese medicine (over 65 years old)	per visit	15.0	1.0	13.5	0.9
	Chinese medicine health guidance for children (6, 12, 18, 24, 30, 36 months old)	per visit	24.0	1.6	21.0	1.4
Health supervision assistance services	Food safety information report of health supervision	per time	565.5	37.7	495.0	33.0
	Occupational health consultation guidance	per time	205.5	13.7	180.0	12.0
	Health supervision assists in the inspection of drinking water health and safety	per time	514.5	34.3	517.5	34.5
	Health supervision and coordination of school health services	per time	171.0	11.4	90.0	6.0
* The gap in the NEPHS EV between eastern and central China was relatively small, so these are combined into one region in the table.
Abbreviations: NEPHSP, National Essential Public Health Services program; EV, equivalent value; TCM, traditional Chinese medicine.

Step 3: Calculate village doctors’ workload in the NEPHS program

Based on the EV of each NEPHS, the workload undertaken by village doctors under the NEPHS program was calculated using the following process:

Share of the workload undertaken by village doctors under the NEPHS program = EVs of services performed by village doctors under the NEPHS program (X) / total EVs of services included in the NEPHS program provided by sampled THCs (Y) × 100%

Y= ∑ EV of each public health service item (A) × volume of each public health service item (B)

X= ∑ EV of each public health service item (A) × volume of each public health service item (B) × village doctors’ share of workload for each public health service item (C)

A: sourced from the EV of each NEPHS in the Table 1;

B: sourced from surveys on the total workload assigned according to the 12 types of service (see section 2.2, Data Collection);

C: sourced from surveys regarding the share of workload undertaken by village doctors in village clinics. This was estimated and reported separately by each service-related department of THCs according to the actual workload conducted by village doctors (see the Data Collection section).

3.1 Workload for different NEPHS provided by village doctors

The total workload of NEPHS was 747982739 EVs across 300 sample THCs from six provinces; village doctors carried out 47.0% of the total workload under the NEPHS program in 2016. The workload share of different NEPHS undertaken by village doctors ranged from 17.1–57.0%; the workload share was more than 50% of health services for patients with hypertension, type II diabetes and severe mental illness whereas it was relatively lower for other services including reporting and management of infectious diseases and public health emergencies, health supervision assistance services and immunizations (Table 2).

Table 2

Workload of different NEPHS provided by village doctors (2016)
Types of essential public health services	Total EVs undertaken by sampled THCs	EVs Undertaken by village doctors	Share of workload undertaken by village doctors (%)
Health records management service	6592311	3265812	49.5
Health education	712789163	336722391	47.2
Immunizations	3863174	1097979	28.4
Health services for children aged 0 to 6 years	6026437	1862762	30.9
Maternal health services	1401484	446129	31.8
Elderly people’s health services	4265152	1782904	41.8
Health services for patients with hypertension	7347198	4187583	57.0
Health services for patients with type II diabetes	1981616	1098258	55.4
Health services for patients with severe mental illness	679617	351801	51.8
Reporting and management of infectious diseases and public health emergencies	116660	19999	17.1
Health management with Chinese medicine	2082677	800327	38.4
Health supervision assistance services	837249	219398	26.2
Total	747982739	351855342	47.0
Abbreviations: NEPHS, National Essential Public Health Services; EV, equivalent value; THC, town hospital center.

3.2 Percentage workload of different NEPHS provided by village doctors in different provinces

Our comparative analysis showed that the percentage workload undertaken by village doctors under the NEPHS program varied in different provinces, with the highest proportion 63.4% and the lowest 28.5%. The workload share for different types of public health services provided by village doctors also varied in different provinces (Table 3).

Table 3

Percentage workload undertaken by village doctors in different provinces (2016), NEPHSP
Types of essential public health services	Province1	Province2	Province3	Province4	Province5	Province6
Health records management service	26.6	48.1	34.9	78.0	52.6	49.4
Health education	35.3	45.6	28.0	59.6	47.2	64.2
Immunizations	34.4	23.1	21.6	26.6	27.8	33.5
Health services for children aged 0 to 6 years	27.6	28.9	37.5	30.2	30.9	30.0
Maternal health services	29.7	34.2	37.9	27.6	24.1	36.1
Elderly people’s health services	44.5	42.8	32.1	48.0	46.3	39.9
Health services for patients with hypertension	53.4	64.2	60.5	59.0	55.3	49.8
Health services for patients with type II diabetes	48.1	55.0	57.2	53.1	55.6	62.0
Health services for patients with severe mental illness	55.8	46.5	51.3	48.1	53.8	54.6
Reporting and management of infectious diseases and public health emergencies	17.9	18.8	14.3	18.6	22.6	13.2
Health management with Chinese medicine	40.0	34.0	39.3	36.7	41.5	38.6
Health supervision assistance services	19.1	41.6	21.3	17.8	18.6	41.0
Total	35.5	45.5	28.5	59.2	47.1	63.4
Abbreviations: NEPHSP, National Essential Public Health Services program.

In this study, we carried out quantitative analysis of the workload of village doctors under the NEPHS program and calculated the share of the total workload among these doctors. Our results showed that 47.0% of the total NEPHS workload was assigned to village doctors by THCs in the six sampled provinces, exceeding the Chinese government’s requirement of 40%. There were differences in the percentage NEPHS workload undertaken by village doctors among different provinces and according to different types of service. The reasons for these differences are unclear and require further research. However, previous studies have shown that shortages and aging of village doctors are two of the main barriers to providing public health services among village doctors. Insufficient training and shortages of necessary medical equipment also restrict village doctors’ ability to provide additional services [19, 22]. Moreover, establishment of unreasonable performance indicators by THCs and unbalanced allowance quotas has largely affected the enthusiasm of village doctors to provide these services [12, 22]. Consequently, differences among the six sampled provinces may be attributed to the number and capabilities of village doctors, performance indicators, allowance quotas for village doctors and other unknown factors [12, 19–20]. The workload undertaken by village doctors in the NEPHS program varies according to type of service, which may be related to village doctors’ age, sex, computer skills and the number of nurses and administrative staff available to support village doctors [22].

The present results generate some possible directions for policy adjustment. It is vital to further strengthen the important role of village doctors in providing NEPHS, to guarantee the availability of these services in rural areas. This study showed that differences exist in the percentage of the NEPHS workload taken on by village doctors according to different provinces and different services, with the percentage workload in some provinces lower than 40%. In terms of the types of services and provinces with a lower share of the workload, governments should focus on those factors can be changed and take appropriate steps, including improving professional skills among village doctors by intensifying professional training, equipping village doctors with the necessary medical facilities and equipment and encouraging them to undertake more work under the NEPHS program by improving performance evaluation and granting a higher program allowance [12, 22]. These measures can also help to stabilize teams of village doctors in the long term. We suggest that governments at all levels use the EV method to conduct district-level analysis of the workload of village doctors under the NEPHS program, to identify priority and influencing factors and implement targeted measures to promote the provision of additional and higher quality public health services by village doctors.

We should note that China’s policy of public health service equalization means that the workload among village doctors is increasing [19]. We must ensure that the workload assigned to these doctors is manageable, based on their individual capabilities [30]. Workloads should not be blindly increased, to avoid undermining rural residents’ access to quality public health services [15, 32]. In our study, the percentage workload undertaken by village doctors in two provinces was more than 60%. We therefore suggest that local governments monitor village doctors’ workload in the NEPHS program using the model developed in this study.

Previous studies have shown that THCs and village doctors have different opinions regarding the workload share and job responsibilities allocated to doctors [34–35]. The measurement in this study may underestimate the workload of village doctors in the NEPHS program. Therefore, a limitation of this research is that we did not investigate workloads from the perspective of doctors in the village clinics themselves. In future, calculations and comparative analyses should be conducted from the perspective of village doctors working in the NEPHS program.

Village doctors play an important role in providing national essential public health services in rural China, but their share of the total workload is unclear. In this study, we established a quantitative analysis approach and found that 47.0% of the total NEPHS workload was assigned to village doctors by THCs in six sampled provinces, exceeding the Chinese government’s requirement of 40%. Differences exist in the percentage of the NEPHS workload undertaken by village doctors among different provinces and services, with the workload proportion in some provinces less than 40%.We suggest conducting district-level analysis of the workload among village doctors under the NEPHS program using the EV method, to identify priorities and influencing factors and implement targeted measures to promote health service provision. The present model based on EV of the NEPHS could be used to monitor village doctors’ workload under the NEPHS program as well to ensure that the workload assigned to village doctors is manageable.

NEPHSP National Essential Public Health Services Program

THC Township Hospital Centers

EV Equivalent value

Ethics approval and consent to participate

The study protocol was approved by the Institutional Review Board of the Capital Institute of Pediatrics, Beijing, China (SHERLL number 2016015). Each participant provided their written consent prior to data collection.

Acknowledgments

We would like to thank the Primary Health Care Division, National Health and Family Planning Commission, for their generous support. We also thank Liwen Bianji, Edanz Group China (www.liwenbianji.cn/ac), for editing the English text of a draft of this manuscript.

Funding

This work was funded by Natural Science Foundation of China (71673191).

Availability of data and materials

Not applicable.

Authors’ contributions

YD, YT, YH, WL and CB were responsible for the conception, design and acquisition of data. YD was responsible for analysis and interpretation of the data and drafting the initial manuscript. YT critically revised the manuscript for important intellectual content. CB was responsible for reviewing all drafts of the manuscript and giving final approval for the version to be published. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

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Model to assess workload of village doctors in the National E sential Public Health Services Program in six provinces of China

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Journal Publication

Version 1

Abstract

1. Introduction

2. Methods

2.1 Sampling

2.2 Data collection

2.3 Model

3. Results

3.1 Workload for different NEPHS provided by village doctors

3.2 Percentage workload of different NEPHS provided by village doctors in different provinces

4. Discussion

5. Conclusions

List of Abbreviations

Declarations

References

Status:

Journal Publication

Version 1