西藏卫生资源配置与利用分析及评价研究
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摘要
研究背景
卫生资源是服务于人类健康事业的要素,主要包括四大资源：人力、物力、财力、信息和管理。新中国成立以来,特别是20世纪80年代改革开放以来,我国的卫生事业得到了长足发展,取得了显著成就,人民群众的健康水平得到了明显改善,居民主要健康指标处于发展中国家前列。与此同时,随着我国经济的快速增长和社会主义市场经济地位的逐步确立,我国卫生事业发展水平与人民群众健康需求及社会经济协调发展的要求不相适应。其中,比较突出的一个问题是卫生资源配置不合理。这是由于我国卫生体制长期受计划经济体制的影响而造成的。我国在卫生资源配置方面主要的问题包括资源配置结构和布局不合理、卫生投入总量不足、卫生资源利用效率低下、以及卫生人力配置失衡等。
当前,我国大多数省、区、市已经根据机构、床位、人员、大型设备和卫生经费等指标制定了卫生资源配置标准或区域卫生规划。西藏自治区作为我国西南边疆少数民族及经济欠发达地区,目前尚未制定此类标准或规划,也是全国唯一一个没有制定卫生资源配置标准的省级辖区。关于西藏卫生资源配置及利用情况的研究报道寥寥无几,特别是针对西藏全区性卫生资源的配置状况更未见有官方或学术领域的研究。
由于特殊的自然、社会、经济和文化环境,国内其它地区成熟的卫生资源配置方法不能简单地适用于西藏情况。西藏需要制定适合自身环境的卫生资源配置标准和方法。因此,对西藏卫生资源配置及利用情况进行调查分析,可以为西藏自治区卫生行政部门在今后制定科学的卫生资源配置标准提供科学依据。同时,本研究也将填补学术界对西藏卫生资源配置方面的研究空白,为将来对该领域的深入研究奠定基础。
研究目的
本研究将分析西藏卫生资源配置及利用状况,针对存在的问题提出更为合理的卫生资源配置和利用方案,为西藏自治区卫生行政部门制定科学的卫生资源配置标准提供依据,发现西藏卫生资源配置过程中的浪费问题,提高卫生资源的使用效率,从而提高西藏卫生服务的质量,促进西藏人民的健康。
具体目标包括：
(1)分析西藏十五年来的卫生资源配置状况；
(2)揭示卫生资源配置和利用的主要影响因素；
(3)发现资源配置现状与卫生服务需求即配置标准方面的差距；
(4)提出完善卫生资源配置和利用的政策建议。
资料来源与方法
资料来源主要包括文献复习、二手资料收集和现场数据调查。其中文献复习包括国内外卫生资源配置研究进展和研究方法；二手资料包括国家和西藏自治区的相关政策、文件和统计年鉴；现场调查数据来源包括对样本地区、县、乡、村各级卫生机构的机构调查和地区、县、乡各级卫生技术人员调查、以及相关知情者访谈等方法所获得的卫生机构基本情况、人力资源配置、基础设施建设、财务收支、医疗设备配置以及卫生服务提供等相关信息。
本研究调查的机构包括林芝、日喀则和阿里三个地区16家人民医院(或卫生服务中心)、16家疾病预防控制中心、3家藏医院、2家妇幼保健院、40家乡镇卫生院及85个村卫生室。样本地区和样本县的卫生技术人员共计1944人,本次调查834人,占样本地区卫生技术人员总数的42.9%,其中地区级448人、县级257人、乡镇卫生院129人。
本研究首先通过文献复习法确定研究空白并建立研究目标。其次,针对研究目标开展现场调查。对现场收集的数据按卫生资源的类别通过比较、描述、归纳、演绎等方法进行分析。第三,对医疗卫生机构资源配置的关键指标利用Gini系数及Lorenz曲线从人口和地理的分布进行公平性分析和评价；同时,利用DEA方法对这些机构的资源配置和利用情况进行效率分析和评价。
主要结果与发现
本研究以卫生人力和医疗设备资源为重点,对样本地区的卫生资源配置与利用状况进行了调查分析。本次研究的主要结果与发现如下：
(1)西藏在1995-2009年15年期间卫生机构、床位和卫生技术人员的总数得到了明显增加,基础设施投入尤其在后三年得到了迅猛的增长。但是,每千人口的卫生技术人员数却没有太大变化,并且每千人口的医生数和护士数呈下降趋势。
(2)所调查地区的地、县、乡、村各级卫生机构普遍缺少人员。各级卫生人员的学历普遍偏低。专业分布方面以西医临床和护理为主,检验和药学方面的人员所占比例较低。所调查地区的卫生人员中具有高级职称的比例极低,无职称者占到24%。在任职资格方面,所调查地区地、县两级卫生机构中具有任职资格的人员占到58.7%,而乡镇卫生院则只有6.6%。
(3)在医疗设备配置方面,所调查地区地、县、乡三级的医疗机构配置较为齐全。部分乡镇卫生院的设备甚至优于、多于县级医院的配置。大部分村卫生室只有少量而简单的设备。还有部分村卫生室未配备任何设备。在医疗设备利用方面,以地区级卫生机构的设备利用率为最高,县级卫生机构、特别是县级疾控中心有不少设备处于闲置、损坏状态,乡镇卫生院的设备利用率为最低。村卫生室基本没有闲置和浪费的设备。
(4)调查发现,影响卫生人力资源配置与利用的主要因素包括三方面：首先西藏的人员引进制度属于计划经济经济时代的模式,所有的人事权都掌握在当地组织人事部门手里,各级卫生机构没有人事自主权。其次,各级卫生机构缺乏有效的人员培养机制,所开展的培训更多是依据能获得的培训机会来进行,很少进行培训需求调查。第三,各级卫生机构普遍缺乏有效的人员激励机制。大多数卫生机构没有建立绩效考核体系,或者绩效体系不健全,不能体现“按劳分配”的原则。
(5)调查发现,影响医疗设备配置与利用的主要因素包括三方面：首先各级卫生机构由于缺乏专业人员而导致部分医疗设备不能利用。其次,许多基层卫生机构由于基础配套设施不到位而造成部分设备得不到利用。第三,在配置设备时未进行需求分析。
(6)所调查地区医疗机构卫生资源配置的公平性分析结果显示,西藏卫生资源的配置越往基层越不公平,特别是按地理面积的配置上,县、乡两级的配置严重不足。所调查地区医疗机构卫生资源配置的DEA效率分析发现,只有15%的乡镇卫生院的资源配置为DEA有效,也只有一半的县级医院和地区级医院的资源配置为DEA有效状态,而其余接近一半的医院处于DEA弱有效或无效。这些医疗机构卫生资源配置无效是由纯技术效率和规模效率下降所造成的,其根本原因是卫生资源投入不足和卫生资源配置在结构上的失衡。
结论与政策建议
本研究的结论包括以下四点：
(1)西藏卫生人力数量总体不足,特别是县、乡、村三级卫生机构的人员数量不足；
(2)西藏卫生人力处于结构失衡状态,各级卫生人员学历和职称普遍偏低；
(3)西藏基层医疗设备利用效率低下,县级疾控中心和乡镇卫生院的相当一部分设备处于被闲置和浪费状态；
(4)西藏卫生资源配置在基层存在较大不公平性,存在卫生资源配置结构失衡和数量不足的问题。
针对以上所发现的问题,本研究提出如下政策建议：
(1)针对西藏特殊的高海拔地理环境和地广人稀的特点,制定有利于卫生人员工作和生活的相关优惠政策,鼓励和引导卫生人员流向基层,特别是县、乡、村三级卫生机构工作；
(2)积极利用西藏大学医学院的教学、科研优势,采用委托培养、定点培养的形式来提升现有卫生人员的学历层次；
(3)利用国家对于西藏民族自治的有利政策,积极协调卫生、教育、人力资源和社会保障等相关部门,制定适合西藏当地情况的有关卫生技术职称评定和任职资格的标准,在保证质量的前提下,来提升西藏卫生系统的中高级技术职称和任职资格比例；
(4)针对基层大量设备被闲置和浪费的问题,制定在本地区或本县内进行设备租赁、二次出售等流转机制,提高设备利用效率。
(5)尽快制定适合西藏特点的卫生资源配置标准,使未来西藏的卫生资源依据人口、地理、需求和基础设施等综合因素进行科学配置。
Background
Health resource is a key element to the human being's health. It comprises five broad catogaries:human resource, physical resource, financial resource, information and management. Since the establishment of the "New China", particularly from the start of the country's reform and opening in the80's of the20century, the health work has developed rapidly with significant achievements being made. The level of the people's health has been greatly improved with key health indicators ranking higher than those of other developing countries. In the meanwhile, along with the rapid economic growth and gradual establishment of the socialism market economy, the level of the health development can not meet the people's needs or the economic development pace. One of the prominent issues is the irrational health resource allocation. This is largely attributed to the long term effect of the planned economy system.
The following are the main issues that are associated with the Chinese health resource allocation:irrational structure and deployment, insufficient overall investment to health, low efficiency of health resource utilization and imbalance in health human resource allocation, etc.
As of today, most of the provinces, regions and municipalities in the country have already made health resource allocation standards or regional health plan, based on indicators including health agency, ward, workforce, large-scale equipment and expenditure. Tibet Autonomous Region, as a place with Tibetans being the dominating residents, economically less developed and bordering other countries, has not made any forms of health resource allocation standards or plans. Very rare research reports on the health resource allocation or utilization can be found in the media or academic arena. No official or academic research activity has ever been undertaken into the Tibet region-wide health reasource allocation status.
Due to its unique natural, social, economic and cultural environment, even well developed health resource allocation standards from other inland places can not be simply adapted to Tibet situation. Suitable standards or plans must be made specifically for Tibet.
It is therefore considered necessary to conduct a survey on the current health resource allocation and utilization status. It is hoped that necessary evidence could b provided to the Tibet Regional Health Bureau for making heath resource allocation standards or plans in the future by conducting such a research activity. It is also hoped that such research could bridge the gap in academics in this area and lay a foundation for further research in the future.
Purpose and objectives
The purposes of this study are to look into the current status of the health resource allocation and utilization, make recommendations for more reasonable health resource allocation and utilization and provide baseline information for Tibet health authorities to make scientific health resource allocation standards. It is also hoped that this study will explore, from theoretical perspective, the possibilities of reducing the waste and improving the efficiency of health resources through out the allocation process. Therefore, it is hoped that the quality of health services provided to the people of Tibet could be improved.
The specific objectives of this study include:
a) Conduct a survey on the health resource allocation status in the last15year period in three selected prefectures;
b) Analyze the influencing factors of the health resource allocation and utilization;
c) Identify the gaps between the current status and health service needs or the allocation standards of the helath resources;
d) Make policy recommendations for improving the current way of health resource allocation.
Source of data and methods
The data of this study primarily includes literature review, existing data and field survey data. The literature review includes research progress and methodology of domestic and international health resource allocation. The existing data includes the national and Tibet Autonomous Region's relevant policies, documents and statistics yearbooks. The field survey data includes the general information of the health agencies, health human resource, infrastructure, financial income and expenditure, medical equipment and health service provision through questionnaire survey and key informant interview of the health agencies and health technical workers from the sample prefectures, counties, townships and villages.
The sample agencies in this study include16people's hospitals (or health service centres),16centres for disease control,3Tibetan medicine hospitals,2mother and child hospitals,40township clinics and85village clinics. Total834out of1944(accounting for42.9%) technical health workers participated in the field survey from the sample prefecture, county and township health agencies, specifically448from prefecture level,257from county level and129from township level. The data collected through field survey is analyzed and appraised from aspects of quantity, structure, equity and efficiency.
This study first identifies research areas and sets research objectives through literature review. Second, field survey is carried out against the objectives. The data collected through field survey are then analyzed by different types of health resources through methods including comparison, description, induction and deduction. Third, the key indicators of the medical institutions are used through Gini Coefficiency and Lorenz Curve to analyze and appraise the equity of the health resource allocation. Meanwhile, the key indicators of the medical institutions are used through DEA to analyze and appraise the efficiency of the health resources allocation and utilization.
Key results and findings
The primary focus of the field survey is on the health human resource and resource. The key results and finding are listed below.
a) Between the15year period of1995and2009, the total number of health institutions, wards and health technical workers has increased. In this period, the infrastructure investment has also increased and became dramatic in the last three years of the period. However, the number of technical health workers per thousand population has not changed significantly. The number of doctors and nurses per thousand population has decreased.
b) There is generally lack of health workers at all levels of prefecture, county, township and village health institutions surveyed. The qualifications of the health workers surveyed are relatively low. The disciplines of the health workers are found to be focused on western clinical medicine and nursing. There is low rate of the health workers holding testing or pharmacy qualifications. It is also found that there is very low rate of health workers holding senior professional qualifications. Those who hold no professional qualifications account for24%. Those who hold job qualifications account for58.7%at the prefecture and county level and only6.6%at the township level.
c) It is found that there is sufficient allocation of medical equipment in the medical institutions at prefecture, county and township levels surveyed. There is better and more medical equipment in some township clinics than the county hospitals. Most village clinics only have a little and simple medical equipment. In terms of medical equipment utilization, it is found that there is a higher rate of utilization at the prefecture level. There is a great deal of medical equipment left being unused or broken at the county level, particularly in some county centers for disease control. The rate of medical equipment utilization at the township is the lowest. There is hardly any medical equipment left being unused or wasted in most village clinics.
d) It is found that there are three primary influencing factors of the Tibet health human resource allocation and utilization. First, the staff introduction policy still stays as the planned economy style. All authorities of personnel allocation belong to the local organization and personnel departments. The health institutions possess none of such authorities. Second, there is generally lack of staff development mechanism at all levels of the health institutions. Most training activities are largely based on the available opportunities. Training needs assessments are rarely carried out prior to any training. Third, there is generally lack of staff motivation mechanism at all levels of the health institutions. Most health institutions surveyed have not set up performance assessment systems or have only set up incomplete systems, which do not reflect the principle of "remuneration distribution on the basis of work"
e) It is found that there are three primary influencing factors of the utilization of medical equipment. First, there is lack of relevant professional technicians who can operate the medical equipment, which results in some types of medical equipment being unused. Second, many health institutions at lower level do not have auxiliary facilities that are essential to the proper use of some medical equipment. Third, there is rarely any needs assessment when allocating medical equipment.
f) It is found that there is more inequity towards the lower level of the health system in Tibet in terms of health resource allocation. There is severely insufficient resource at the county and township levels by geographical distribution. It is found that only15%of the township clinics and about half of the county and prefecture hospitals appear to be DEA efficient in terms of resource allocation. The rest clinics and hospitals lie in either weakly efficient or inefficient status in terms of resource allocation. The inefficiency of the resource allocation in these health institutions is primarily attributed to decreasingly trend of the pure technical efficiency and scale efficiency. The root causes of this are insufficient health resource allocation and structural imbalance of health resource allocation.
Conclusions and policy recommendations Based on the findings, this study concludes as follows.
a) The total quantity of health workforce in Tibet is insufficient. This is particularly the case at county, township and village levels.
b) The health workforce in Tibet is in an imbalance structure. The academic qualification and professional qualification levels are both generally low.
c) The utilization rate of the medical equipment in the lower leve health institutions is low. A great deal of equipment has been left unused and wasted in the county centre for diseases and township clinics.
d) The health resources are unfairly allocated at lower level of Tibet. There are imbalance structure and insufficient amount in health resource allocation at this level.
Based on the issues identified above, the following policy recommendations are made out of this study.
a) To make favourable policies for the health workers in terms of work and living conditions, with consideration of the Tibet's special characters of high altitude and widely scattered population, in the hope that health workers can be encouraged and directed to the lower level, particularly the county, township and village level health institutions.
b) To take advantage of the teaching and research functions of Tibet University Medical College for staff qualification upgrading on specific contractual basis.
c) To take advantage of the autonomous favourable policies issued by the national government to make suitable standards for the health workers' professional qualification assessment and medical practice qualification assessment in Tibet, in close consultation with the departments of health, education and human resource&social insurance, for the purpose of increasing the rates of the middle and senior professional qualification and medical practice qualification.
d) With the great amount of medical equipment left being unused and wasted, effective mechanism should be made to ensure such equipment to be rented or resold to others in the county or prefecture to increase the utilization of the resource.
e) To make suitable health resource allocation standards for Tibet as early as possible to ensure future health resource allocation is made in a scientific way, with consideration of population, geography, needs and infrustracture conditions.
卫生资源是服务于人类健康事业的要素,主要包括四大资源：人力、物力、财力、信息和管理。新中国成立以来,特别是20世纪80年代改革开放以来,我国的卫生事业得到了长足发展,取得了显著成就,人民群众的健康水平得到了明显改善,居民主要健康指标处于发展中国家前列。与此同时,随着我国经济的快速增长和社会主义市场经济地位的逐步确立,我国卫生事业发展水平与人民群众健康需求及社会经济协调发展的要求不相适应。其中,比较突出的一个问题是卫生资源配置不合理。这是由于我国卫生体制长期受计划经济体制的影响而造成的。我国在卫生资源配置方面主要的问题包括资源配置结构和布局不合理、卫生投入总量不足、卫生资源利用效率低下、以及卫生人力配置失衡等。
当前,我国大多数省、区、市已经根据机构、床位、人员、大型设备和卫生经费等指标制定了卫生资源配置标准或区域卫生规划。西藏自治区作为我国西南边疆少数民族及经济欠发达地区,目前尚未制定此类标准或规划,也是全国唯一一个没有制定卫生资源配置标准的省级辖区。关于西藏卫生资源配置及利用情况的研究报道寥寥无几,特别是针对西藏全区性卫生资源的配置状况更未见有官方或学术领域的研究。
由于特殊的自然、社会、经济和文化环境,国内其它地区成熟的卫生资源配置方法不能简单地适用于西藏情况。西藏需要制定适合自身环境的卫生资源配置标准和方法。因此,对西藏卫生资源配置及利用情况进行调查分析,可以为西藏自治区卫生行政部门在今后制定科学的卫生资源配置标准提供科学依据。同时,本研究也将填补学术界对西藏卫生资源配置方面的研究空白,为将来对该领域的深入研究奠定基础。
研究目的
本研究将分析西藏卫生资源配置及利用状况,针对存在的问题提出更为合理的卫生资源配置和利用方案,为西藏自治区卫生行政部门制定科学的卫生资源配置标准提供依据,发现西藏卫生资源配置过程中的浪费问题,提高卫生资源的使用效率,从而提高西藏卫生服务的质量,促进西藏人民的健康。
具体目标包括：
(1)分析西藏十五年来的卫生资源配置状况；
(2)揭示卫生资源配置和利用的主要影响因素；
(3)发现资源配置现状与卫生服务需求即配置标准方面的差距；
(4)提出完善卫生资源配置和利用的政策建议。
资料来源与方法
资料来源主要包括文献复习、二手资料收集和现场数据调查。其中文献复习包括国内外卫生资源配置研究进展和研究方法；二手资料包括国家和西藏自治区的相关政策、文件和统计年鉴；现场调查数据来源包括对样本地区、县、乡、村各级卫生机构的机构调查和地区、县、乡各级卫生技术人员调查、以及相关知情者访谈等方法所获得的卫生机构基本情况、人力资源配置、基础设施建设、财务收支、医疗设备配置以及卫生服务提供等相关信息。
本研究调查的机构包括林芝、日喀则和阿里三个地区16家人民医院(或卫生服务中心)、16家疾病预防控制中心、3家藏医院、2家妇幼保健院、40家乡镇卫生院及85个村卫生室。样本地区和样本县的卫生技术人员共计1944人,本次调查834人,占样本地区卫生技术人员总数的42.9%,其中地区级448人、县级257人、乡镇卫生院129人。
本研究首先通过文献复习法确定研究空白并建立研究目标。其次,针对研究目标开展现场调查。对现场收集的数据按卫生资源的类别通过比较、描述、归纳、演绎等方法进行分析。第三,对医疗卫生机构资源配置的关键指标利用Gini系数及Lorenz曲线从人口和地理的分布进行公平性分析和评价；同时,利用DEA方法对这些机构的资源配置和利用情况进行效率分析和评价。
主要结果与发现
本研究以卫生人力和医疗设备资源为重点,对样本地区的卫生资源配置与利用状况进行了调查分析。本次研究的主要结果与发现如下：
(1)西藏在1995-2009年15年期间卫生机构、床位和卫生技术人员的总数得到了明显增加,基础设施投入尤其在后三年得到了迅猛的增长。但是,每千人口的卫生技术人员数却没有太大变化,并且每千人口的医生数和护士数呈下降趋势。
(2)所调查地区的地、县、乡、村各级卫生机构普遍缺少人员。各级卫生人员的学历普遍偏低。专业分布方面以西医临床和护理为主,检验和药学方面的人员所占比例较低。所调查地区的卫生人员中具有高级职称的比例极低,无职称者占到24%。在任职资格方面,所调查地区地、县两级卫生机构中具有任职资格的人员占到58.7%,而乡镇卫生院则只有6.6%。
(3)在医疗设备配置方面,所调查地区地、县、乡三级的医疗机构配置较为齐全。部分乡镇卫生院的设备甚至优于、多于县级医院的配置。大部分村卫生室只有少量而简单的设备。还有部分村卫生室未配备任何设备。在医疗设备利用方面,以地区级卫生机构的设备利用率为最高,县级卫生机构、特别是县级疾控中心有不少设备处于闲置、损坏状态,乡镇卫生院的设备利用率为最低。村卫生室基本没有闲置和浪费的设备。
(4)调查发现,影响卫生人力资源配置与利用的主要因素包括三方面：首先西藏的人员引进制度属于计划经济经济时代的模式,所有的人事权都掌握在当地组织人事部门手里,各级卫生机构没有人事自主权。其次,各级卫生机构缺乏有效的人员培养机制,所开展的培训更多是依据能获得的培训机会来进行,很少进行培训需求调查。第三,各级卫生机构普遍缺乏有效的人员激励机制。大多数卫生机构没有建立绩效考核体系,或者绩效体系不健全,不能体现“按劳分配”的原则。
(5)调查发现,影响医疗设备配置与利用的主要因素包括三方面：首先各级卫生机构由于缺乏专业人员而导致部分医疗设备不能利用。其次,许多基层卫生机构由于基础配套设施不到位而造成部分设备得不到利用。第三,在配置设备时未进行需求分析。
(6)所调查地区医疗机构卫生资源配置的公平性分析结果显示,西藏卫生资源的配置越往基层越不公平,特别是按地理面积的配置上,县、乡两级的配置严重不足。所调查地区医疗机构卫生资源配置的DEA效率分析发现,只有15%的乡镇卫生院的资源配置为DEA有效,也只有一半的县级医院和地区级医院的资源配置为DEA有效状态,而其余接近一半的医院处于DEA弱有效或无效。这些医疗机构卫生资源配置无效是由纯技术效率和规模效率下降所造成的,其根本原因是卫生资源投入不足和卫生资源配置在结构上的失衡。
结论与政策建议
本研究的结论包括以下四点：
(1)西藏卫生人力数量总体不足,特别是县、乡、村三级卫生机构的人员数量不足；
(2)西藏卫生人力处于结构失衡状态,各级卫生人员学历和职称普遍偏低；
(3)西藏基层医疗设备利用效率低下,县级疾控中心和乡镇卫生院的相当一部分设备处于被闲置和浪费状态；
(4)西藏卫生资源配置在基层存在较大不公平性,存在卫生资源配置结构失衡和数量不足的问题。
针对以上所发现的问题,本研究提出如下政策建议：
(1)针对西藏特殊的高海拔地理环境和地广人稀的特点,制定有利于卫生人员工作和生活的相关优惠政策,鼓励和引导卫生人员流向基层,特别是县、乡、村三级卫生机构工作；
(2)积极利用西藏大学医学院的教学、科研优势,采用委托培养、定点培养的形式来提升现有卫生人员的学历层次；
(3)利用国家对于西藏民族自治的有利政策,积极协调卫生、教育、人力资源和社会保障等相关部门,制定适合西藏当地情况的有关卫生技术职称评定和任职资格的标准,在保证质量的前提下,来提升西藏卫生系统的中高级技术职称和任职资格比例；
(4)针对基层大量设备被闲置和浪费的问题,制定在本地区或本县内进行设备租赁、二次出售等流转机制,提高设备利用效率。
(5)尽快制定适合西藏特点的卫生资源配置标准,使未来西藏的卫生资源依据人口、地理、需求和基础设施等综合因素进行科学配置。
Background
Health resource is a key element to the human being's health. It comprises five broad catogaries:human resource, physical resource, financial resource, information and management. Since the establishment of the "New China", particularly from the start of the country's reform and opening in the80's of the20century, the health work has developed rapidly with significant achievements being made. The level of the people's health has been greatly improved with key health indicators ranking higher than those of other developing countries. In the meanwhile, along with the rapid economic growth and gradual establishment of the socialism market economy, the level of the health development can not meet the people's needs or the economic development pace. One of the prominent issues is the irrational health resource allocation. This is largely attributed to the long term effect of the planned economy system.
The following are the main issues that are associated with the Chinese health resource allocation:irrational structure and deployment, insufficient overall investment to health, low efficiency of health resource utilization and imbalance in health human resource allocation, etc.
As of today, most of the provinces, regions and municipalities in the country have already made health resource allocation standards or regional health plan, based on indicators including health agency, ward, workforce, large-scale equipment and expenditure. Tibet Autonomous Region, as a place with Tibetans being the dominating residents, economically less developed and bordering other countries, has not made any forms of health resource allocation standards or plans. Very rare research reports on the health resource allocation or utilization can be found in the media or academic arena. No official or academic research activity has ever been undertaken into the Tibet region-wide health reasource allocation status.
Due to its unique natural, social, economic and cultural environment, even well developed health resource allocation standards from other inland places can not be simply adapted to Tibet situation. Suitable standards or plans must be made specifically for Tibet.
It is therefore considered necessary to conduct a survey on the current health resource allocation and utilization status. It is hoped that necessary evidence could b provided to the Tibet Regional Health Bureau for making heath resource allocation standards or plans in the future by conducting such a research activity. It is also hoped that such research could bridge the gap in academics in this area and lay a foundation for further research in the future.
Purpose and objectives
The purposes of this study are to look into the current status of the health resource allocation and utilization, make recommendations for more reasonable health resource allocation and utilization and provide baseline information for Tibet health authorities to make scientific health resource allocation standards. It is also hoped that this study will explore, from theoretical perspective, the possibilities of reducing the waste and improving the efficiency of health resources through out the allocation process. Therefore, it is hoped that the quality of health services provided to the people of Tibet could be improved.
The specific objectives of this study include:
a) Conduct a survey on the health resource allocation status in the last15year period in three selected prefectures;
b) Analyze the influencing factors of the health resource allocation and utilization;
c) Identify the gaps between the current status and health service needs or the allocation standards of the helath resources;
d) Make policy recommendations for improving the current way of health resource allocation.
Source of data and methods
The data of this study primarily includes literature review, existing data and field survey data. The literature review includes research progress and methodology of domestic and international health resource allocation. The existing data includes the national and Tibet Autonomous Region's relevant policies, documents and statistics yearbooks. The field survey data includes the general information of the health agencies, health human resource, infrastructure, financial income and expenditure, medical equipment and health service provision through questionnaire survey and key informant interview of the health agencies and health technical workers from the sample prefectures, counties, townships and villages.
The sample agencies in this study include16people's hospitals (or health service centres),16centres for disease control,3Tibetan medicine hospitals,2mother and child hospitals,40township clinics and85village clinics. Total834out of1944(accounting for42.9%) technical health workers participated in the field survey from the sample prefecture, county and township health agencies, specifically448from prefecture level,257from county level and129from township level. The data collected through field survey is analyzed and appraised from aspects of quantity, structure, equity and efficiency.
This study first identifies research areas and sets research objectives through literature review. Second, field survey is carried out against the objectives. The data collected through field survey are then analyzed by different types of health resources through methods including comparison, description, induction and deduction. Third, the key indicators of the medical institutions are used through Gini Coefficiency and Lorenz Curve to analyze and appraise the equity of the health resource allocation. Meanwhile, the key indicators of the medical institutions are used through DEA to analyze and appraise the efficiency of the health resources allocation and utilization.
Key results and findings
The primary focus of the field survey is on the health human resource and resource. The key results and finding are listed below.
a) Between the15year period of1995and2009, the total number of health institutions, wards and health technical workers has increased. In this period, the infrastructure investment has also increased and became dramatic in the last three years of the period. However, the number of technical health workers per thousand population has not changed significantly. The number of doctors and nurses per thousand population has decreased.
b) There is generally lack of health workers at all levels of prefecture, county, township and village health institutions surveyed. The qualifications of the health workers surveyed are relatively low. The disciplines of the health workers are found to be focused on western clinical medicine and nursing. There is low rate of the health workers holding testing or pharmacy qualifications. It is also found that there is very low rate of health workers holding senior professional qualifications. Those who hold no professional qualifications account for24%. Those who hold job qualifications account for58.7%at the prefecture and county level and only6.6%at the township level.
c) It is found that there is sufficient allocation of medical equipment in the medical institutions at prefecture, county and township levels surveyed. There is better and more medical equipment in some township clinics than the county hospitals. Most village clinics only have a little and simple medical equipment. In terms of medical equipment utilization, it is found that there is a higher rate of utilization at the prefecture level. There is a great deal of medical equipment left being unused or broken at the county level, particularly in some county centers for disease control. The rate of medical equipment utilization at the township is the lowest. There is hardly any medical equipment left being unused or wasted in most village clinics.
d) It is found that there are three primary influencing factors of the Tibet health human resource allocation and utilization. First, the staff introduction policy still stays as the planned economy style. All authorities of personnel allocation belong to the local organization and personnel departments. The health institutions possess none of such authorities. Second, there is generally lack of staff development mechanism at all levels of the health institutions. Most training activities are largely based on the available opportunities. Training needs assessments are rarely carried out prior to any training. Third, there is generally lack of staff motivation mechanism at all levels of the health institutions. Most health institutions surveyed have not set up performance assessment systems or have only set up incomplete systems, which do not reflect the principle of "remuneration distribution on the basis of work"
e) It is found that there are three primary influencing factors of the utilization of medical equipment. First, there is lack of relevant professional technicians who can operate the medical equipment, which results in some types of medical equipment being unused. Second, many health institutions at lower level do not have auxiliary facilities that are essential to the proper use of some medical equipment. Third, there is rarely any needs assessment when allocating medical equipment.
f) It is found that there is more inequity towards the lower level of the health system in Tibet in terms of health resource allocation. There is severely insufficient resource at the county and township levels by geographical distribution. It is found that only15%of the township clinics and about half of the county and prefecture hospitals appear to be DEA efficient in terms of resource allocation. The rest clinics and hospitals lie in either weakly efficient or inefficient status in terms of resource allocation. The inefficiency of the resource allocation in these health institutions is primarily attributed to decreasingly trend of the pure technical efficiency and scale efficiency. The root causes of this are insufficient health resource allocation and structural imbalance of health resource allocation.
Conclusions and policy recommendations Based on the findings, this study concludes as follows.
a) The total quantity of health workforce in Tibet is insufficient. This is particularly the case at county, township and village levels.
b) The health workforce in Tibet is in an imbalance structure. The academic qualification and professional qualification levels are both generally low.
c) The utilization rate of the medical equipment in the lower leve health institutions is low. A great deal of equipment has been left unused and wasted in the county centre for diseases and township clinics.
d) The health resources are unfairly allocated at lower level of Tibet. There are imbalance structure and insufficient amount in health resource allocation at this level.
Based on the issues identified above, the following policy recommendations are made out of this study.
a) To make favourable policies for the health workers in terms of work and living conditions, with consideration of the Tibet's special characters of high altitude and widely scattered population, in the hope that health workers can be encouraged and directed to the lower level, particularly the county, township and village level health institutions.
b) To take advantage of the teaching and research functions of Tibet University Medical College for staff qualification upgrading on specific contractual basis.
c) To take advantage of the autonomous favourable policies issued by the national government to make suitable standards for the health workers' professional qualification assessment and medical practice qualification assessment in Tibet, in close consultation with the departments of health, education and human resource&social insurance, for the purpose of increasing the rates of the middle and senior professional qualification and medical practice qualification.
d) With the great amount of medical equipment left being unused and wasted, effective mechanism should be made to ensure such equipment to be rented or resold to others in the county or prefecture to increase the utilization of the resource.
e) To make suitable health resource allocation standards for Tibet as early as possible to ensure future health resource allocation is made in a scientific way, with consideration of population, geography, needs and infrustracture conditions.
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