Table 4-1 provides the list of all the indicators selected. The table also shows the sources and years for which data were available.
Table 4-1. Indicators of structural and functional balance between primary and hospital care
Domain Sub-domain Indicator Sources of data Available years
Structure Human resources
1.1 Number of staff 40YR, CHY (1990-2002), CHSY (2003-2014)
2.1 Value of assets CHSY (2005-2014) 2004-2013 2.2 Number of beds 40YR, CHSY (2003-2014) 1949-2013 2.3 Number of valuable
devices
CHSY (2004-2014) 2003-2013
2.4 Building space CHY 1991, CHSY (2004-2014)
1989, 2002-2013 Function Service
utilisation
3.1 Number of visits 40YR, CHSY (2003-2014) 1981-2013 3.2 Number of
Financing 4.1 Revenues CHY (1997-2004), CHSY (2004-2014)
2004-2013
Notes: 40YR = Health Statistics Information in China (1949-1988); CHY = Chinese Health Yearbook;
CHSY = Chinese Health Statistics Yearbook
1) Indicators for human resources
Human resources are a critical factor within the structural domain and featured prominently in previous studies (see Chapter 2). Under the sub-domain of “human resources”, indicators were selected to reflect the quantity and quality of staff.
Indicator 1.1: Number of staff
Measuring quantity of staff involves the issue of the pluralistic nature of human
resources. While both total number of staff and number of selected types of staff (particularly doctors) provide useful information, data availability for the latter was more limited. Therefore, I decided to use the total number of staff for all types of facilities between 1949 and 2013. Availability of data for certain types of facilities was also restricted (see Figure 4-3). For total staff number of all hospitals, data were available only for the period between 1984 and 2013 and the sum of staff numbers of hospitals above the level of county under the government health sector and county hospitals were used for the years before 1984, implying underestimation of the number of hospital staff. It should be noted that each staff member was counted as one without distinguishing the proportion of time they spend working as health practitioners, as such data were not available. In particular, village health workers (barefoot doctors and health personnel) were supposed to participate in collective agricultural work besides health work. Hence, this measure could give an exaggerated impression regarding certain groups of practitioners who normally worked part time (particularly barefoot doctors).
Indicator 1.2: Qualification of health practitioners
Measuring quality of staff involves again the issue of the plural nature of human resources, and there are also different ways to measure the quality of health practitioners. First, it was possible to compare both health practitioners of a specific type and health practitioners as a whole. Since comparison of the qualification of staff across the board could be difficult to interpret, it seemed reasonable to confine the analysis to doctors only, as they were the key decision makers in clinical care. Second, it is possible to compare the level of qualification using different criteria. There were two types of qualifications, namely professional qualifications and academic qualifications.
Two systems of professional qualification existed during the past decades in China,
namely, a system of technical qualification (zhicheng 职称) and a system of licensing (zhizhao 执照). A policy document issued in 1956 clarified health professionals into three main grades of technical qualification. Correspondingly, three professional titles were given for each grade of practitioners: shi ( 师 , roughly translated as a
“professional”) corresponded to high grade practitioners, shi (士, roughly translated as a “practitioner”) corresponded to middle grade practitioners, and yuan (员, roughly translated as “personnel”) corresponded to primary (i.e. low) grade practitioners (Ministry of Health, 1956b). The grading system reflected professional competence, generally a combination of academic achievement and work experience. Hence, the proportion of “professionals” was a good indicator of the quality of doctors. This regulation was revised in 1986, when the qualification system changed. From then on, the high grade corresponded to chief (or deputy chief) professionals, the middle grade corresponded to executive professionals, and the primary grade corresponded to (general) professionals and practitioners (Ministry of Health, 1986b). The change probably reflected the improvement in training of health practitioners in the country.
However, it also meant that the proportion of “professionals” became less useful as an indicator of quality of staff, because both could be with a lower level of training.
The percentage of professional doctors among all practitioners was thus a useful measurement of quality for the periods between the 1950s and 1980s. However, statistics on human resources were generally reported as either in urban or rural areas (i.e. within urban districts or rural counties), and were not distinguishable by hospitals and primary care facilities except for within rural areas only. As a result, two alternative methods were used for these years. The first method used urban facilities to represent hospitals, and rural facilities to represent primary care facilities. The rationale was that urban hospitals were the predominant health facilities in urban areas in terms of human resources, while primary care facilities dominated the rural areas.
The other alternative method looked only at rural hospitals (county hospitals) and rural
primary care facilities. For both methods, data were available for the years between 1952 and 1988. Except for a negligible fraction of professional doctors practising integrated Chinese and Western medicine in the 1980s, professional doctors practising Western medicine were the only professional practitioners (the total of practitioners could be practising Chinese medicine, Western medicine or integrated Chinese and Western medicine). Hence this measurement reflected the quality of doctors mainly from the perspective of biomedicine.
An alternative way to measure professional qualification was related to the licences each level of doctor held. Various types of licences allowed different ranges (types and locations) of services. Available data on licences were restricted to more recent years (2002-2013). Above the level of village, doctors were required after 1992 to have a licence or assistant licence in order to practice (Ministry of Health, 1993).
Besides professional qualifications, there were academic qualifications, i.e. the level of educational qualification (e.g. secondary schools or university degrees). Data regarding educational level were also not available until recently (for selected years between 2002 and 2013). Therefore, the qualification of health practitioners between 1989 and 2013 was operationalized as the percentage of professional grade doctors among all practitioners; percentage of practitioners with full practicing licenses; and percentage of practitioners with university degrees. Unfortunately, data about both percentage of professional doctors and percentage of practitioners with university degrees were unavailable for the years between 1989 and 2001.
Indicator 1.3: Average annual income of staff
Earnings of primary care professionals as compared with specialists has been used as an indicator for the orientation of a health system towards primary care by Starfield (1994). Such data, however, were not routinely collected. Instead, national statistics
etc.) in various types of health facility between 2004 and 2013. This information could be used together with the information about the number of staff in each type of health facility to calculate average income. The income was adjusted for inflation using the price level of 2000 (see Appendix Table 1).
2) Indicators for assets, equipment and infrastructure
Assets not only are an important indicator of accumulated inputs but also represent the physical capacity of health facilities to provide services. The value of assets provides a representation of the overall non-human capital of a particular type of facility. Such factors have been particularly important in the historical and contemporary balance between primary and hospital care in China. As both primary care facilities and hospitals provided inpatient services, inpatient beds were important assets. Involvement in hospitalization-based services has been considered an important opportunity to improve doctors’ clinical experience and competence (Honigsbaum, 1979). Similarly, equipment and infrastructure are important conditions for doctors and other health practitioners to expand clinical service capacity. As facilities generally did not share devices and infrastructure with each other, an important aspect of technical capacity of facilities was the possession of valuable devices (including diagnostic and other devices). As building space is an important measurement of the infrastructure of facilities, and the only one for which data were available, it was selected as an indicator for infrastructure.
These indicators of non-human capital arguably favour hospitals disproportionately and imbalance in such factors is expected. Nevertheless, including non-human capital serves to balance the bias towards primary care when only human resources are concerned. Hence, under the sub-domain of “assets, equipment and infrastructure”, four indicators were chosen regarding the value of assets, number of beds, number of valuable devices, and building space. Except for the number of beds,
the data under this sub-domain were available only for the recent decade.
Indicator 2.1: Value of assets
Data were available for the years between 2004 and 2013 for hospitals and primary care facilities (with a break down consisting of township health centres, community health centres and stations, sub-district health centres and private clinics). The value of assets was adjusted for inflation using the price level of 2000.
Indicator 2.2: Number of beds
The number of beds were reported for hospitals, township health centres, and community health centres and stations. While data for hospitals were available from 1949 onwards, data for township health centres and community health centres and stations were available only for the period after these types of facility became popular (i.e. from 1959 and from 2002, respectively).
Indicator 2.3: Number of valuable devices
The total value of all devices above 10,000 yuan (price unadjusted) was used as the indicator of possession of high-value devices. Data were available for the period between 2003 and 2013 for hospitals, primary care facilities as a whole, and township health centres. An alternative measure was the number of all devices valued above 10 thousand yuan each. However, data for this covered only the years between 2007 and 2013, and the value of each device for inflation could not be adjusted. Therefore, the number of devices with value above 10,000 yuan at the price level of corresponding years was used.
Indicator 2.4: Building space
The working definition for the indicator is the total construction space of all buildings (including rented space) under each type of facility. Data were reported for
hospitals, township health centres, village clinics and community health centres (stations), sub-district health centres, and private clinics, first in 1988 and then generally continuously between 2003 and 2013.
3) Indicators for service utilisation
The sub-domain of service utilisation consisted of three indicators, namely, number of visits, number of admissions, and visits to admissions ratio. Patient visits (consisting overwhelmingly of ambulatory patient visits, but also including emergency care, home visit, health check-up, and health consulting) were a key indicator of services utilized by patients in both hospitals and primary care facilities. Changing proportions and absolute number of visits reflected the change in the functional role of a particular level/type of facilities. Inpatient services had been a significant function of primary care facilities in China as mentioned above. Township health centres, particularly, had been a significant provider of inpatient services. It should be expected though that the nature and severity of inpatient services would be different between hospitals and primary care facilities, but such data were not available. Therefore, the numbers regarding service utilisation were not adjusted for changes in population, as different population groups (particularly rural vs urban residents) appeared to be using different types of facility at varied frequencies.
Indicator 3.1: Number of visits
Annual patient visits were used to measure number of visits. Data availability for different types of facility varied. While the number of visits was reported for hospitals as early as in 1952, the number of visits to township health centres was not available before 1981. Comparison between 1952 and 1980 was not meaningful and therefore omitted. Visits to village health clinics and to community health centres and stations were reported from only 2003/2004 onwards.
Indicator 3.2: Number of admissions
The operational definition for the indicator of inpatient services was the number of hospitalisations at hospitals and township health centres from 1981 to 2013. Data for the years before 1981 were dropped from the analysis, because admissions to hospitals only were reported.
Indicator 3.3: Visits to admissions ratio
The visits to admissions ratio measured the number of ambulatory visits per inpatient for each type of facility. This indicator reflects the overall trend regarding balance of outpatient and inpatient care in hospitals and primary care facilities between 1981 and 2013. Among primary care facilities, data were available only for township health centres between 1981 and 2003. Data for other primary care facilities were included only between 2003 and 2013.
4) Indicators for financing
Chapter 2 suggested that resource allocation was an important measure of the functional balance that has featured in previous studies. Here total revenue of facilities was used as an indicator to reflect the resources utilised for patient services. Revenue also complemented indicators on quantity of services as a better reflection of service function in terms of intensity of services from a financial perspective.
Indicator 4.1: total revenue
Total revenue measures the annual total amount of revenue of health facilities.
Data for total revenue by type of facility were reported for 2004 and 2013.
4.4 Results