A study on satisfaction with publicly financed health services in China

Chinese healthcare reforms are designed to combine four types of health services, including public health (public financed health services), health insurance, health services, and drug supply for both urban and rural residents in order to form one integrated basic health care system (the Central People’s Government of the People’s Republic of China, 2016). Overall satisfaction with health services is generally related to the quality of the services received or to be received. Concerns about variations in access to quality publicly financed health care services for urban and rural residents are all contemporary public policy concerns in China. With implementation of universal healthcare, the performance of urban and rural residents’ healthcare and the degree of satisfaction with publicly financed health services have become a hot issue in assessing health reforms in China.

Chinese public health policy is more and more closely in accordance with the developing trend of international public health services. Satisfaction with publicly financed health services is one important indicator to measure health system performance and its evaluation index system is the main issue focused by previous researchers. Thomas [1] classified healthcare into three types (primary care, secondary care and tertiary care) from low level to high level, according to healthcare activities, specialization and severity. Zhang [2] classified healthcare into three categories: public healthcare, quasi public healthcare and private properties of healthcare services. Although some scholars believed that contracting for the delivery of health services could be very effective and that kind of improvements could be rapid [3, 4], the priority arrangement in healthcare, which was of growing importance, promoted the combination of constrained resources and the increasing demands of healthcare [5]. International studies of health services satisfaction evaluation started earlier, and the evaluation system is still improving. Shackley and Donaldson [6] addressed that the willingness to pay for publicly-financed healthcare could reveal the residents’ satisfaction to some extent. At present, relatively mature international evaluation model includes four models: Donabedian evaluation model, which focuses on “the organization structure, the health resources, work and the result”; Italy’s Piedmont evaluation model, which emphasizes on “behavior index, equality index, productivity index and life quality index”; Sackett services object model and Parker’s system evaluation model [7]. Arnold Leving [8] suggested the Delphi expert consultation is the effective way to establish index system with a program selection on purpose.

Chinese scholars have begun a preliminary exploration of related evaluation contents and index of healthcare based on health system performance assessment framework suggested by WHO. Generally, China’ s evaluation model for community public health services can be divided into two models,“support-process-effect” model and “devotion-service-efficiency” model, and both of them have their own specific support index. In terms of index system, Liang [9] established a set of evaluation index system of China’s urban community health services with Delphi expert consultation for two rounds of inquiry by gathering experts from domains of general medicine, clinical medicine, health education and health economics. Cui [10] also used this kind of method to summarize the indexes from aspects of health input, public health services items, health services management, services implementation effect and services charge and performed the results from experts in SPSS, getting the arithmetic average, weighted average, variation coefficient and cooperation index of the experts’ suggestions in questionnaire and Ni [11] assumed the exercise and fitness, health supervision and coordination services, elder healthcare and health education are main indexes whose weight coefficient are top high by the Delphi method. Chen [12] calculated the weight of indexes with fuzzy comprehensive evaluation, concluding that the highest weight coefficient is the aspect of service items including vaccination, children and women healthcare, infectious diseases and health emergence, health education and major psychosis management. Yu et al. [13] carried out the dimensionless method targeting on the features of evaluation system, getting the comprehensive performance index of public health services and finally obtained 4 main indexes: health care spending, reimbursement range, monthly health situation and physical examination times. Xu and Deng [14] analyzed factors summarized from previous scholars employing the correlative and factor analysis and got changes in health situation, resident health record and health supervision were the main factors affecting the satisfaction of public health services. Chen and Li [15] and Tian [16] employed the RSR method AHP method to confirm that the index system consists of annal hospitalization, chronic diseases management, major psychosis management, etc. Liang [9] adapted the Crowns Bach coefficient method and the principal component factor analysis to evaluate the validity and reliability of community health services model’s index system. In terms of actual investigation and study, Zhou et al. [17] analyzed community health services performance from the level of hospital services and community health services for the first time and measured the response level of community health services in Shenzhen using one-way ANOVA and Fuzzy math assessment. Huang et al. [18] conducted a research of Kwangtung in China on the satisfaction of public health, resulting to the idea that 70% to 85% of respondents are satisfied with public health management of the society. Zhang [19] also verified the result that health information management, health education, resident health record and children, women or elder healthcare are the essential indexes with Delphi method when all of experts’ suggestions tending to uniform. The methods mentioned above are employed to select and screen factors or indexes in the public health performance evaluation system. We chose the selected indexes according to mature and former scholars’contribution to conduct second confirmation with a new model like the multiple linear regression model and logistic regression model, getting more exact and accurate factors affecting the satisfaction. Before that, we used Likert scale to investigate the level of satisfaction, getting the attitude to public health services of 1198 urban and rural residents in five cities (Zhenjiang, Dongguan, Chengdu, Shenmu, Yinchuan) from the perspective of the demand side of health services, which is creative compared with the former researches from the aspects of services providers. The project also analyzed the factors of public health services based on the empirical analysis in order to explore how to improve the satisfaction with public health services among urban and rural residents.

This paper is organized in the following manner. In Methods, the methods are presented. Descriptive statistics analysis reports descriptive results on satisfaction by urban and rural residents with publicly financed health services. Factor and multivariate regression analyses that account for variations in satisfaction are presented in Results and Discussions, respectively. Conclusions and Limitations present the conclusions and limitations.

Through descriptive statistics, we may get a macro view of our sample’s information and respondents’ basic information such as their age, educational background, hospitalization rate, frequency of taking exercise and monthly health condition shown in Table 6. As to satisfaction with publicly financed health services displayed in Table 1, we can understand overall satisfaction with publicly financed health services, the different scores and their specific characteristics among different people and regions, describing public health services satisfaction by the use of Likert scale so we interpret the mean of each indexes of satisfaction which indicated the general level of public health satisfaction. Overall satisfaction with basic publicly financed health services is 3.00, which is in the mid-range on the five-point scale and is reflective of neither dissatisfaction nor satisfaction with services. Among these scores, satisfaction score for health supervision and coordination services is 2.82, lower than other scores, while satisfaction with vaccinations is at the other end of the spectrum with a score of 3.24. From the perspective of different people, rural residents report the highest overall satisfaction score, with a score 3.00; while urban residents have the lowest satisfaction score which is 2.88. From an overall perspective, satisfaction scores for publicly financed health services in five typical areas of China (Zhenjiang, Guangdong, Chengdu, Shenmu, Yinchuan) are all around 3. We can conclude that satisfaction with health services for urban and rural residents is neutral. Detailed data can be seen in Table 1.

In order to comprehensively analyze the main determinants of satisfaction reported by urban and rural residents, we create a binary satisfaction variable that is 1.0 when reported as neutral or better satisfaction (ie they reported being “totally satisfied”, “satisfied” or “neutral”) and 0 otherwise. We choose binary variable as independent variable because it was often used in reliable literatures and it was easier to understand the result when using binary variable. To assess the determinants of satisfaction, we use the same set of variables that were previously reported to be significant, as shown in Table 10. These results imply that infectious diseases and health emergence, chronic diseases management, resident heath record, vaccination, children healthcare, women healthcare, elderly healthcare and major psychosis management whose P value are less than 0.05 based on the 95% confidence interval are the main factors affecting public health satisfaction. The odds ratio in this retrospective study which represented the relative risk reduction in prospective study can be seen from the Exp(B). Take chronic diseases management for example, the odds ratio of it is 1.390, so this kind of management contributes 0.39(1.39–1) to the satisfaction with public health services. According to the significance level, resident health record, vaccination, child healthcare, elder healthcare, major psychosis management have significant correlation with satisfaction. Therefore, improving health records, timely vaccination, elder care for women or elder, pediatric care and major psychosis management will exert conducive influence on satisfaction with publicly financed health services.

We surmise that introducing specific public health policy aiming at special groups, detailed and informative public health management, public healthcare publicity and accessible public health services is effective measurement that can be taken smoothly by public sectors. We also learn what can be done to improve satisfaction with publicly financed health services from previous researches literatures. Liang [9] suggested that government should take the burden of public health and intensify its role-playing with the forced supervision and management. Cui [10] hold ideas that the barren and poverty-stricken areas need to be input in public health. Ni [11] concluded that general practitioner training should be carried out in order to strengthen the guidance of medical care. Huang et al. [18] revealed in his researches in Kwangtung that policy related to public health need to adept to the different groups according to different social economics status. Our research summarize following conclusions referring to statistical analysis.

What can be done to increase the degree of satisfaction with health services needs to be considered based on our findings. Regression analysis based on the survey data finds that health records, vaccinations, pediatric care, elder care, and mental health management are the main factors accounting for degree of satisfaction with publicly financed health services for both urban and rural residents. Therefore, with improvements in health records, timely vaccination, elder care for women or elder, pediatric care and major psychosis management, degree of satisfaction with publicly financed health services are likely to grow.

There are several limitations in this study. First up, the random selection only covers 1250 urban and rural residents in five Chinese regions. We hope to expand the scope of the survey and increase sample size to enhance the conclusion we have got from this survey in the future although our sample is representative enough. Moreover, some results of the sample are missing or distorted in this survey because of some uncontrollable and subjective reasons (for example, the limitation of the resident’s culture, especially in some undeveloped areas) affecting the results. What’s more, some omitted factors leading to inaccurate estimates probably make the impact factors incomprehensible although we have controlled variables as much as possible. Exceptionally, the research methodology is simplified among other models which lead the similar results, we just use the oridinal logistic regression model to confirm the result, but we didn’t list all of them one by one, it would be better if it can include other models to confirm the results and show reasons why some models can not be employed. In the future, the study will focus on collecting more data from other reign of China and make a comparison between different models for this motif. At last, we did not took subjective factors into account, this is what we will do in further researches.