Zhou Huixuan, Zhang Shengfa, Zhang Weijun, Wang Fugang, Zhong You, Gu Linni, Qu Zhiyong, Tian Donghua
China Institute of Health, School of Social Development and Public Policy, Beijing Normal University, 19 Xinjiekou Wai Street, Haidian District, Beijing, 100875, China.
BMC Public Health. 2015 Feb 27;15:199. doi: 10.1186/s12889-015-1540-9.
The Chinese government has increased the funding for public health in 2009 and experimentally applied a contract service policy (could be seen as a counterpart to family medicine) in 15 counties to promote public health services in the rural areas in 2013. The contract service aimed to convert village doctors, who had privately practiced for decades, into general practitioners under the government management, and better control the rampant chronic diseases. This study made a rare attempt to assess the effectiveness of public health services delivered under the contract service policy, explore the influencing mechanism and draw the implications for the policy extension in the future.
Three pilot counties and a non-pilot one with heterogeneity in economic and health development from east to west of China were selected by a purposive sampling method. The case study methods by document collection, non-participant observation and interviews (including key informant interview and focus group interview) with 84 health providers and 20 demanders in multiple level were applied in this study. A thematic approach was used to compare diverse outcomes and analyze mechanism in the complex adaptive systems framework.
Without sufficient incentives, the public health services were not conducted effectively, regardless of the implementation of the contract policy. To appropriately increase the funding for public health by local finance and properly allocate subsidy to village doctors was one of the most effective approaches to stimulate health providers and demanders' positivity and promote the policy implementation. County health bureaus acted as the most crucial agents among the complex public health systems. Their mental models influenced by the compound and various environments around them led to the diverse outcomes. If they could provide extra incentives and make the contexts of the systems ripe enough for change, the health providers and demanders would be receptive to the transition of the policy.
The innovative fund raising measures could be taken by relatively developed counties of China to conduct public health services. Policymakers could take systems thinking as a useful tool to design plans and predict the unintended outcomes during the process of public health reforms.
中国政府于2009年增加了对公共卫生的资金投入，并于2013年在15个县试点实施了一项合同服务政策（可视为家庭医学的对应政策），以促进农村地区的公共卫生服务。该合同服务旨在将数十年来一直个体行医的乡村医生转变为政府管理下的全科医生，并更好地控制肆虐的慢性病。本研究罕见地尝试评估合同服务政策下提供的公共卫生服务的有效性，探索其影响机制，并为未来政策的推广得出启示。
采用立意抽样法，从中国东部到西部选取了三个试点县和一个在经济和卫生发展方面具有异质性的非试点县。本研究采用案例研究方法，通过文献收集、非参与观察以及对84名卫生服务提供者和20名多层次需求者进行访谈（包括关键信息人访谈和焦点小组访谈）。采用主题分析法，在复杂适应系统框架内比较不同结果并分析机制。
在缺乏充分激励措施的情况下，无论合同政策是否实施，公共卫生服务都无法有效开展。通过地方财政适当增加公共卫生资金投入，并合理分配对乡村医生的补贴，是激发卫生服务提供者和需求者积极性、促进政策实施的最有效途径之一。县卫生局在复杂的公共卫生系统中扮演着最为关键的角色。其受周围复杂多样环境影响的思维模式导致了不同的结果。如果他们能够提供额外激励，并使系统环境成熟到足以促成变革，卫生服务提供者和需求者将接受政策的转变。
中国相对发达的县可以采取创新的筹资措施来开展公共卫生服务。政策制定者可以将系统思维作为一种有用的工具，来设计计划并预测公共卫生改革过程中的意外结果。
