Context
Chongyi, the intervention site, is a small county in a remote mountain area. It has a population of 203,438, of which 165,214 work in agriculture. The fiscal revenue of local government was 307,700,000 Yuan and net average income of farmers for the whole year was 3,406 Yuan per capita in 2008, which is below the 2008 average per capita net income of rural residents in China (4,761Yuan). The economic conditions of Chongyi County are representative of depressed rural areas. There is a fairly sound three-level health service system (village, township and county). Luxi (the comparison site) is also a small county in mountain area adjacent to Chongyi in Jiangxi province. It has a population of 286,300 and an agricultural population of 227,733. The fiscal revenue of local government was 378,000,000 Yuan in 2008. The per capita annual income was 5047 Yuan.
Before the implementation of the project, there were no appraisal standards for township hospitals and village clinics. Rural doctors were not aware of the importance of proactive care, passively relying on patients initiating contact with the doctor. They did not provide planned visits for patients with chronic diseases such as hypertension, diabetes and special populations such as maternal, children and the elderly.
Data collection
Officers from county health bureau and postgraduates from School of Public Health, Nanchang University interviewed the staff in each township hospital and village clinic together, using a questionnaire. The questions were adapted from the national health resources and medical service survey system [
13]. They included questions about health service buildings and facilities, equipment, service functions and staff numbers, as well as types of service carried out. According to “Jiangxi township hospitals construction standards”, the following services should be conducted: - disease prevention and health care; basic medical treatment; family planning; and health management. Thus respondents were asked to indicate if the following specific areas were provided:
Public health functions including:
○ Establishment of family health records
○ Immunization
○ Infectious disease control
○ Chronic non-communicable diseases prevention and treatment (eg hypertension)
○ Maternal and child health care
○ Aged care and rehabilitation
○ Family planning counseling
○ Health education
Clinical care including the provision of
○ Routine physical check
○ Laboratory check
○ TCM basic technology
○ Gynecological routine inspection
○ Referral in
○ Referral out
○ Home visit
○ Home care
○ Home sickbed
This questionnaire has been used in previous field studies by the School of Public Health.
Intervention model
1.
The development of the model
CHS policies and reports from urban and more economically advanced rural areas (e.g. Zhejiang, Jiangsu) were reviewed and joint visits were conducted to examine the model of rural CHS in Zhejiang Province. Analysis of policy and a literature review provided the foundation from which we developed the initial Chongyi County CHS Model. This was then refined by a multi-stage process of iterative feedback and revision in consultation with the county government in 2009. Participants in this consultation came from the relevant branches of the health, social security, civil administration and financial administration in the county. The model was continually revised in response to the multiple stakeholder consultations, using a method similar to that used to develop performance measurement for CHSs [
14]. Participants discussed the CHS progress, achievements and problems, and were asked a series of open-ended questions. Examples of questions included: “Is the rural CHS in Chongyi sustainable?” and “Should there be any immediate outcomes of services provided by CHS facilities?” A record was made of the consultation meetings. This was analysed thematically and summarized. This was then provided to the participants for comment. Finally they were used to refine model, revise regulations, standards and incentive polices.
2.
Main features of the model
The model introduced the concept and organization of CHSs and aimed to strengthen the capacity of health-care institutions at township and village levels. At village level, public health services to be introduced included special clinics for maternal health, child health, immunization and chronic disease; health education using health materials; outreach into people’s homes; establishing health records for the whole population. At township level, public health and clinics were introduced along with development of a role in health management, supervision and education of doctors in Village Health Service Stations. At all these levels, a single electronic health record system was developed based on a card that provided access to health records and health insurance. The record system was accessible via secure Internet link at village, township and county level.
3.
Implementation of the model
The steps involved in implementation included:
(1)
Promoting involvement of the county government in the development of primary health care(PHC).
Engagement of rural government officials was achieved through seminars, individual interviews, joint review of relevant documents, and joint visits to examine the model of rural CHSs in Zhejiang province. The local government established a group to lead rural CHS work, with leadership from the relevant branches of the health, social security, civil administration and financial administrations. This helped to integrate PHC into the government’s work plan and to develop policies to promote PHC.
(2)
Improving the skills of PHC practitioners.
Training aimed to improve the individual skills of primary health care workers. The project group conducted a 1-week training course for 40 health managers, 160 doctors and 40 nurses. This included both theoretical education and field-based training. Theoretical training included social medicine, community medicine, general medicine, community health service, community nursing, and health management. Chongyi County also sent 20 doctors from township hospitals in two batches to participate in transition training (6 months GP training) conducted by the provincial health department. The immediate impact of the training on their knowledge, attitudes and stated practice was assessed using a questionnaire before and after the training. These were analyzed to evaluate the quality of training.
(3)
Improving management processes in PHC
Chongyi County health management regulations were revised and the Chongyi County CHS standards were drafted. The major standards were based on those in urban areas, adapted for conditions in depressed rural areas. They were discussed and revised three times by government officials (provincial, municipal, county and township) and the experts from the university.
To encourage medical workers at village and township levels to carry out effective PHC, incentive policies for rural CHSs were introduced in Chongyi County. The policies included funding for repair or refurbishment of clinic premises and some additional equipment (computer, examination bed, simple test equipment). By establishing these township and village health facilities as new rural cooperative medical care institutions, the rural doctors were able to access subsidies for public health service work (e.g. home visits, immunizations, patient education).
During the study, the management systems of rural community health services were improved:
In the business management system, planning for immunizations, emergency treatment for public health emergencies, women health care, child health care, geriatric care, community-based rehabilitation, health education, family planning and technical guidance was established or enhanced.
In technical norms and work systems, procedures for emergency first aid, outpatient work, and the responsibilities for initial diagnosis were improved.
In the management systems for rural community health service stations, standards for the behavior of community health service staff, the responsibilities of general practitioners, the responsibilities of community nursing, elder care work, prescription management and disinfection management were established. Also the technical specifications of treatment rooms were modified.
Continuing education and technical appraisal, quality improvement supervision, accident prevention, medical waste disposal and pharmacy staff education were improved.
In the comparison sites in Luxi County, these interventions were not provided and township and village health facilities provided usual care.
Funding
The intervention was resourced largely by the Health Bureau of Chongyi County. This included funding for repair and refurbishment of clinical premises and provision of some additional equipment. It also included the time of county staff involved in training and supervision and travel costs.
The training of health administrators, township and village doctors and community nurses was funded by project funds the China-Australia Health and HIV/AIDS Facility. The project funds also included travel and accommodation for evaluation field staff and visits by the Australian consultant to Chongyi.
Incentives for rural doctors’ work were provided through the rural cooperative health insurance scheme and funding for public health services.