Evaluation and mechanism for outcomes exploration of providing public health care in contract service in Rural China: a multiple-case study with complex adaptive systems design

Abstract

BackgroundThe 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.MethodsThree 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.ResultsWithout 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.ConclusionsThe 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.

Financing strategies to improve essential public health equalization and its effects in China

“…Although many studies proved that the causal association between the public health expenditure and infant or child mortality [9,10], some studies well summarized China's experience on public health in 1949-1984 [3,16] and lessons in 1985-2002 [4,17], some studies assessed the effects of NEPHSP on service coverage and equity [14,[40][41][42][43][44][45][46][47][48], very few studies described China's financing strategies and mechanisms for the NEPHSP [34,35,41,43]. This study could be an important contribution to the exiting literature on evaluation of public health equalization in China.…”

“…The government also purchase the public health services by signing a contract with the private sector such as village doctors and the latter receive a modest subsidy for providing public health services associated with the package. The willingness of village doctors to provide public health services has been improved since the introduction of the package and a minimum subsidy, although village doctors do not find the subsidy to be sufficient remuneration for their efforts [42][43][44].…”

Opportunities and Challenges of Implementing Service Agreement between the Government and Faith Based Organizations in Ilala Municipality, Dar Es Salaam, Tanzania

“…This was similarly reported in other studies done in Sub Saharan Countries 10,11,15,23,29,31 whereby government was unable to send funds on time as agreed on SA. This was also reported by a study on SA conducted in China whereby provincial government did not send money to barefoot doctors as agreed 14 , thus affecting the effective implementation of SA as originally planned.…”

“…This was also reported in another study done in Chinaon evaluation and mechanism for outcomes exploration of providing public health care in contract service in Rural China whereby the provincial governements were not conducting supervision as agreed. 14 This study found that existence of guidelines and policies help to describe the procedures and ways that implementers of any plan need to follow in order to achieve certain results or outcomes of interest. This study found that the existence guidelines and policies on the implementation of SA is an opportunity for provision of guidance and direction by the government on how to implement, monitor and evaluate the progress of SA.…”

“…1,8,13 One proposed approach to improve coverage and quality of health care for all citizens was to enter into contract with private organizations to deliver speci c services that are pre-de ned by health authorities. 1,2,10,14,15 Public Private Partnership in the Health and Social Welfare Sector can take a variety of forms with differing degrees of public and private sector responsibility and risk. They are characterized by the sharing of common objectives, as well as risks and rewards, as de ned in a contract or agreement.…”