The section provides an overview of the research approaches and methods used in the thesis to address each objective, while full methodological details are provided in corresponding chapters or parts. Each objective is dealt with using a specific research approach, except for the last two objectives (methodological reflection and policy implications) which draw from all other sub-studies (see Table 3-1).
3.2.1 The overall study design
Figure 3-1 is a graphical summary of how the four sub-studies constituted a multi-approach study on the balance between primary and hospital care. The thesis addresses the conceptual complexity of the balance discussed in Chapter 2 by dividing the issues involved into three levels (shown on the left side of the diagram). The three levels of issues involved in shifting the balance between primary and hospital care include: an identifiable policy intervention (represented as the thinner oval); a contemporary system (represented as the wider oval) involving a broad range of inter-connected health systems factors directly or indirectly related to the intervention, the interaction among which can be captured in a cross-section; and a historical system (represented as the shape of a large arrow, with a shaded arrow below representing the underlying
axis of time), where temporal sequence is critical in setting a long term dynamic. The two ovals and the large arrow overlap and are linked with circular arrows in the diagram, reflecting the embeddedness of intervention in the contemporary system and the contemporary system in the historical system. The diagram represented the recognition that the three levels are closely interrelated and need to be investigated together to form a comprehensive assessment of the situation and future strategies.
Figure 3-1. Summary of overall study design
Having conceptualized shifting the balance between primary and hospital care as involving three levels, the thesis relied on four sub-studies to address the three levels (shown on the right side of the diagram), and two “integrative analyses” to synthesize findings of all sub-studies. The first sub-study (trend analysis) measured the changing structural and functional aspects of the balance to provide a background for the historical-institutionalist analysis. The second sub-study (historical-institutionalist analysis) tried to explain the historical evolution of the balance, drawing from the theoretical lens of path dependence theory, and treating factors involved in the coevolution of primary and hospital care over the long term as a historical system. The third sub-study (impact evaluation) investigated the effectiveness of the gatekeeping
pilot, seen as an intervention. The fourth sub-study (qualitative systems analysis) dealt with the functioning of the gatekeeping pilot, seen as a contemporary system. While the four sub-studies were conducted in parallel, the remaining two integrative analyses drew on the findings of all four sub-studies, focusing on their interconnectedness (represented by circular arrows) and reflected on the methodological significance, substantive findings and policy implications.
3.2.2 Describing historical trends of the balance between primary and hospital care
To address Objective 1, a descriptive study assessed the historical trend of the balance between primary and hospital care in China. Due to data availability issues, the period studied was limited to the years from 1949 to 2013. As a systematic way of measuring the balance between primary and hospital care did not exist, the sub-study built on the findings of the literature review in the previous chapter, and developed a system of metrics, involving 11 indicators, to measure the structural and functional domains of the balance. The structural domain included indicators on human resources, assets, equipment and infrastructure. The functional domain include indicators that measure service utilisation and revenue. Data for both hospitals and primary care facilities were sourced from official national health statistics, including a statistical report that covered the 40 years between 1949 and 1988, the series of national health yearbooks that covered the years between 1949 and 2008, and the series of national health statistical yearbooks that covered the year between 1949 and 2013.
3.2.3 Analysing the historical logic of evolution of the balance between hospitals and primary care providers
To address the second objective of understanding the historical logic of the coevolution of primary and hospital care in China, a historical-institutionalist sub-study was conducted. The sub-sub-study covered the years from 1835 to 2013, divided into
three periods segmented by 1949 and 1978. For the analysis, a dynamic path dependence analytical framework was developed, building on the critical juncture analysis approach (Capoccia, 2015). Data about main actors were collected from an extensive range of sources, including: relevant historical studies/accounts; official documentations of history; local archives; anthologies, biographies, and memoirs;
journals and newspapers; and three propagandist paintings.
3.2.4 Impact evaluation of the gatekeeping pilot
To address Objective 3—evaluating the effectiveness of a pioneering gatekeeping pilot in shifting the balance between primary and hospital care, a difference-in-differences study design was applied. This impact evaluation used the pilot townships as a treatment group and non-pilot townships as a control group and compared the different trends of key outcome variables both before and after the start of the pilot and across intervention and control areas. Claims and enrolment data were used in econometric analysis. The study covered a population of around 21,000 in 17 townships, in the 12 quarters from 2012 to 2014. The sub-study was limited by the small scale: two small rural townships in a vast and varied country.
3.2.5 Systems analysis of the functioning of the gatekeeping pilot
To address Objective 4--understanding the functioning of the gatekeeping pilot, the thesis developed and used an approach of qualitative systems analysis, which combined a categorisation of health system building blocks, a qualitative method for policy analysis and causal loop analysis. Over two years (2014 and 2015) during the gatekeeping pilot programme, 20 stakeholders (including patients, doctors, facility managers and health administrators) were interviewed. The health systems categorisation was used to develop question guides for the interviews. The
“Framework” approach of policy analysis was used to analyse the data from the field work. A causal loop diagram was drawn and used to assist the analysis and present the
results. Again, the sub-study was limited by the small scale of implementation.
3.2.6 Ethics
Ethical approval for this study (impact evaluation and qualitative systems analysis) was provided by the Institutional Review Board for Biomedical Ethics at Peking University (IRB00001052-14024-MIAN) and the Research Ethics Committee at the London School of Hygiene & Tropical Medicine (PR/123/123).
3.3 Summary
This chapter has laid out the aims and objectives, as well as the methodological framework of the thesis. The study design included four sub-studies, which constituted a contemporary evaluation of a pioneering gatekeeping pilot and a historical study of the development of the balance between hospitals and primary care providers in China.
Chapter 9 and 10 will revisit methodological issues of this study design.