Background
Mental health, ignored for far too long, is crucial to the overall well-being of individuals, societies, and countries. In recent years, mental health issues have become more prevalent, impacting people of all ages and financial levels worldwide[
1]. Globally, three-quarters of the mental, neurological, and substance use disorder burden was experienced by people from developing countries; China alone accounted for nearly 17% of the global burden[
2]. Furthermore, according to a survey conducted in 31 Chinese provinces, the lifetime prevalence of mental disorders among adults was 16.6%[
3]; given China’s population of 1.4 billion, this prevalence ratio suggests that many people are affected by mental health problems.
The reduction in the mental disorder burden in China is essential and urgent. However, the resources provided to tackle the enormous burden, such as financial investment[
4,
5], professional staff[
6,
7], and medical institutions[
8‐
10], remain insufficient and unevenly distributed. According to a National Health Commission report, two-thirds of China’s counties and districts do not have mental health institutions. Moreover, mental health resources are mainly located in the eastern coastal provinces[
5]. A Chinese Center for Mental Disease Control and Prevention survey found that 47.21% of mental health institutions, 42.06% of beds, and 46.22% of professional staff are concentrated in East China. Surprisingly, in ten provinces (Shanxi, Inner Mongolia, Jilin, Heilongjiang, Anhui, Tibet, Gansu, Qinghai, Ningxia, and Xinjiang), more than 50% of counties have no mental health institutions[
8].
The Chinese government has prioritized ensuring that all citizens’ right to health is protected. Over the past ten years, it has implemented corresponding measures to enrich mental health resources and address health resource maldistribution[
11]. First, making a better mental health system has been incorporated into the national health system reform. Much policy and financial support has been given to build mental health institutions and attract professionals, especially in West and Central China[
12]. Second, ten national ministries and commissions, such as the Ministry of Health, the National Commission of Development and Reform, the Ministry of Finance, and the Ministry of Civil Affairs, have jointly formulated the National Mental Health Work Plan[
10]. The plan specifies targets for resource allocation in different regions and strategies to ensure implementation. Finally, the National Mental Health Law of the People’s Republic of China was adopted by the National People’s Congress on October 26, 2012, and it took effect on May 1, 2013. Different sections of the law discuss the prevention and rehabilitation of mental disorders, the financing and management of services, the provision of social welfare services for patients and their families, and the responsibilities of different agencies and community members in the mental health effort[
13]. Many scholars agree that the law will play an unparalleled role in establishing a better mental health service system in China[
13,
14].
Mental health beds are a pivotal component of mental healthcare resources. How to optimize the allocation of mental health beds has been a concern of policymakers and scholars in different countries[
15‐
17], including China. Moreover, as a rule in China, the hospital bed is the anchor for the deployment of health professionals. For example, according to the Basic Standards for Medical Institutions issued by the Ministry of Health, a mental hospital needs to meet the standard of 0.4–0.55 professionals per bed[
18]. Understanding the current state of mental health bed allocation, particularly the equity of allocation, is an issue that cannot be ignored in the development and optimization of health policy. In recent years, researchers have begun to focus on this issue. Many studies have investigated mental health bed allocation quantity and inequity in China, and they have observed disparities in mental health beds across different regions[
4,
6,
8,
16,
19]. However, they did not evaluate trends in changes in mental health bed allocation equity over time and its relation to China’s mental health laws and policies in the last ten years. Existing research primarily focuses on measuring the degree of inequity in the demographic distribution. We believe geographical area should be considered, as geographical accessibility is an important aspect of health equity[
20,
21]. In terms of research methods, many quantitative indicators are extensively used to measure health resource equity[
22‐
24], including the Gini coefficient, Lorenz curve, Theil index, Concentration index, and Atkinson index. These indicators are straightforward and practical. For example, when paired with Gini coefficients, the Lorenz curve might vividly show equality in resource allocation[
25]; the Theil index could reflect the contribution rate within and between groups when examining the major reasons for inequity[
26]. Nevertheless, mental health policy researchers have paid little attention to these methods.
Therefore, in cases of nonuniform distributions of mental health care needs across regions, we aimed to evaluate the trend of equity in mental health bed allocation in not only demographic but also geographic terms in China over the last ten years, from 2011 to 2020. The Lorenz curve, Gini coefficient, and Theil index were used in this study. The findings of this study may help reflect the impact of the government’s efforts to improve health resources and provide a theoretical foundation for policymakers to take appropriate measures to optimize the allocation of mental health beds.
Discussion
The Chinese government attaches great importance to health care. In recent years, a series of measures have been taken to promote the development of the mental health system. This study shows that the number of mental health bed resources in China increased steadily from 2011 to 2020, and the density of beds increased as well. The implementation of a series of medical reform measures, particularly the Mental Health Prevention and Control System Construction and Development Plan, which was launched by the National Development and Reform Commission, the Ministry of Health, and the Ministry of Civil Affairs in 2010[
33], is closely linked to this result. From 2011 to 2015, the central and local governments spent 16.9 billion yuan rebuilding and expanding 549 mental health institutions, equipping 648 mental health institutions with basic medical equipment, and helping general hospitals establish psychiatric departments[
34]. Our study discovered that the increase in bed density in the western region is particularly noticeable, reflecting the government’s priority in allocating mental health resources to this region. In fact, the Chinese government enacted the Construction Plan of the National Health Protection Project[
35] in 2015 to support the construction of six major projects, including health poverty alleviation, public health service capacity enhancement, and difficult and complicated diseases enhancement, as well as promoting the flow of medical resources to the grassroots level and western regions. This plan requires that new beds be tilted towards areas such as psychiatry when strengthening the construction of county-level hospitals.
The policy initiatives mentioned above have shown good results. However, there remains a disparity in the allocation of mental health beds between China and high-income countries. According to the data of the World Mental Health Atlas 2020, the allocation level of mental health beds in high-income countries is 5.1 per 10,000 people[
17], while China has only 4.6 per 10,000 people. In fact, it is inappropriate to compare China to high-income nations due to their disparate economic, cultural and medical systems. And many high-income countries are reducing the number of mental health beds as part of a broader effort to deinstitutionalise mental health patients. However, like many low- and middle-income countries, mental health services in China have a long way to go in achieving the goal of providing good mental health care in the community[
5]. With a population of more than 1.4 billion, China has a large demand for mental health bed resources. Especially in the case of the outbreak of the COVID-19 pandemic, sufficient mental health resources become even more crucial[
36,
37]. As a result, it is suggested that the government continue to increase the allocation of mental health beds(especially in primary health care) by increasing policy support and financial guarantees. In addition, the impact of the COVID-19 outbreak on the demand for mental health services must be considered.
In this study, the Gini index was used to reflect the overall equality, while the Theil index was used to decompose the sources of inequity. To gain more insight, we evaluated the equality of mental health beds based on both population and geographic area. We found that equity in resource allocation has been improving annually over the past decade. According to population allocation, overall equality is relatively fair. Nonetheless, it is in a highly inequitable state according to geographic area. This result is not surprising since most resource planning programs were based on population allocation, with few focusing on geographic areas. Correspondingly, the equity of resource allocation by population was much better than that by geographical area. Many scholars have reached the same conclusion[
7,
30]. However, it is pleasing to note that the “Healthy China 2030” plan, released by the Communist Party of China Central Committee and the State Council, takes fairness and justice as one of the plan’s basic principles[
38]. According to the plan, primary health care resources should be distributed fairly based on resident population and service area. As a result, inequity in mental health bed resources by area may improve in the future.
From the perspective of inequity decomposition, mental health bed resources in China are unevenly distributed across regions, and intraregional inequity is the main contributor. The findings are consistent with those of previous studies on the allocation of healthcare resources in terms of expenditure[
4], facilities[
39,
40], medical equipment[
41] and professionals[
30]. Moreover, we found that the inequity in mental health bed allocation mostly came from within the western region. By taking the number of mental health beds per 10,000 square kilometres in 2020 as an example, the value of Chongqing was 2400 times that of Tibet. Therefore, the allocation of mental health beds in the western region needs to be optimized. However, this is not an easy job. On the one hand, the western region is vast, but many areas are sparsely populated; on the other hand, the western region is home to ethnic minorities, such as Tibetans and Uyghurs, and has unique cultural-religious characteristics[
42]. How mental health services are sought may differ between the western region and the central and eastern regions. For example, residents in the western region may seek help from Tibetan Buddhist or Tibetan traditional medicine when they suffer from illness[
43,
44]. Therefore, policymakers should consider all of these factors to promote the rational allocation of mental health services in the western region.
The Chinese government has taken many initiatives and achieved great results in addressing the huge burden of mental disorders. However, China’s mental health service system development and service delivery still face many difficulties[
45]. In addition to optimizing mental health beds and associated human resources, timely assessment of needs, appropriate public health policies, development of new psychotropic drugs and effective interventions, strengthening of human capacity and efficient mobilization of financial resources are also important and need to be concerned. Furthermore, information technology positively impacts access to medical care for patients in rural groups and those far from medical resources[
46,
47]. Health information interventions, such as telemedicine, internet-based helplines and mental health mobile apps, are expected to achieve health equity and reduce the burden on existing mental health services. In general, promoting health equity is a systemic project. Therefore, it is recommended that the government should follow a holistic approach and consider the whole picture when allocating mental health resources.
Limitations
It is important to recognize the limitations of this study. First, the research object of this article is the mental health beds in 31 provinces in China. We did not further subdivide mental health beds into different categories. Future studies need to be conducted by focusing on specialized mental health bed categories, such as public and private, profit and nonprofit, mental hospitals, mental health beds in general hospitals and community residential facilities. Second, this study mainly analyses the equity of mental health bed resource allocation from the perspective of demography and geography, without considering the actual mental health status and mental health service needs of different regions. Future studies should consider more factors to comprehensively evaluate mental health bed allocation. Third, in addition to mental health beds, health service indicators, especially the number of health professionals and the amount of public expenditure, should be emphasized in the allocation plan of mental health beds.
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