Service utilization in community health centers in China: a comparison analysis with local hospitals

Since they are considered an important part of the Chinese Urban Health Reform System, Community Health Centers (CHCs) have been established throughout the entire nation; they are currently undergoing substantial re-construction. Until 2002, 31 provinces including the autonomous regions and central government-ruled cities such as Beijing, Shanghai, ChongQing and Tianjin had a total of around 2406 CHCs and 9700 service stations. However, these CHCs are facing many problems in delivering their services, attributable to the different speeds of development among centers, lack of resources, and imbalance in the sizes of CHCs, so it is difficult for them to meet citizens' needs. Nevertheless, the CHCs are considered the main primary institutions for offering basic medical and public health services. They are regarded as the basic networks for medical treatment and public health surveillance. Therefore, redistributing health resources towards CHCs can ensure social health equality [1].

Traditional health methods such as Traditional Chinese Medicine (TCM) concentrate more on cure than prevention and/or care. By the beginning of the 21^st century, traditional methods could no longer cope with the tasks of the new CHCs or patients' health service demands such as care, emergency treatment and rehabilitation. Hence, there is an urgent need to develop the CHC services in order to meet the residents' demands. The main question is how to develop these centers and expand them, and at the same time be able to attract patients to use them. Another important question is how to build a trusting, stable and harmonious doctor-patient relationship. These are all important variables in the advancement of the Chinese health reform system.

The study was approved by Peking University Health Science Center Institutional Reviewing Board (NO: IRB00001052-T1)

The initial quantitative assessment design was applied to six cities chosen from regions of South-East China – Guangzhou, Foshan, Shenzhen, Fuzhou, Xiamen and Hangzhou. Three hospitals (1 medium-large and two large) and three CHCs were chosen randomly "by lots", and data samples were collected from the local health bureaux. We have emphasized hospital size in order to indicate patient turnover in the outpatient departments per number of staff per day and the number of patients attending according to their needs, which vary from one hospital to another. The 3 CHCs, chosen randomly from three cities, were almost identical in the size of their facilities. Also, we investigated the utilization of health resources in each city and the standard of living in each community. All data were processed using SPSS software. Analytical methods mainly included descriptive analysis, paired T-tests, one-way ANOVA, etc. (Table 1).

We also conducted a household survey in the six cities in order to ascertain residents' knowledge about the CHCs' six functions. A total of 3000 questionnaires were distributed, 500 in each city. Of these, 2563 were returned and found valid. The remaining 437 questionnaires were invalid; 148 were returned but not fully answered, 232 were returned blank and 57 were lost. The response rate was 85.45%. The following questions were analyzed (Table 2).

Under the items "medical income per 100 Yuan fixed assets" and "proportion of administrative to total expenditure" (Table 1), there was no obvious difference between the local hospitals and the CHCs. In the three items "average professional income per staff", "level of person-time charge for outpatient service" and "average outpatients per staff", the utilization of health resources was higher in local hospitals than in the community medical health institutions. Overall, the utilization in large and medium-large local hospitals is generally higher than in the CHCs. Residents visit the local hospitals no matter whether their diseases are acute or chronic because people trust hospitals. This has led to an influx of too many people into local hospitals, which was described by the Chinese Ministry of Health as "difficult to see a doctor" and "expensive to see a doctor". The CHCs have difficulty in winning the trust of the local residents owing to the scarcity of medical resources such as lack of funds, absence of newest medical technology (diagnostic equipment could rarely be seen in these centers), and few professional and qualified medical staff (especially in the rural areas). For these same reasons, it is difficult for other community health care tasks to be carried out smoothly. In general, medical officers working in the CHCs are not qualified enough to gain the residents' trust because they are not always up to date on the latest medical information. Furthermore, many physicians working in the CHCs either have not received a bachelor degree in medicine, that is, they are medical technicians, or could not secure hospitals jobs owing to poor professional quality and turned to work in a CHC, or are specialized physicians but unable to deliver a primary care service. Furthermore, it is important to elaborate on topic concerning the medical staff working in the CHCs, about their qualification and their professional quality, which has been detected widely around the CHCs and can affect the deliverance of good or poor quality service. Since hospitals cannot dismiss their employees, hence, they displace them to the CHCs. Those who are displaced are either because they showed low quality of professionalism or because there isn't enough space to accommodate them anymore. Thus, the displaced employees work temporarily-for a short period of time until they find a suitable position in other hospitals-causing some setbacks in delivering an efficient service due to the continuous change in the staff most of the time. So, the reason behind the low quality of service in the CHCs is related to both low quality of clinicians and continuous change in the staff. There are no specific data on this issue either from the Ministry of Health or from China Statistical Bureaux. Thus, future studies are needed to explore furthermore on this issue.

Table 2 shows that the percentage of residents who have knowledge about the medical treatment performance service of the CHCs falls in the highest percentile (98.6%), and the second best-known function is prevention and control. The awareness rate of "Community rehabilitation" is 42.2% because most residents consider community rehabilitation to be part of the medical treatment function. However, residents have a low rate of awareness about the health-care service function and health education, and most responders believe that both the latter functions should be implemented by health administrators. Furthermore, residents have the same understanding about the importance of the five functions. All residents hope that the CHCs can be well constructed and effectively managed, but at the same time they are dissatisfied with the services provided by the CHCs. Satisfaction rates all fall under 70% except for "Health education", which is 75.5%. The rate for "Medical treatment service" is only 21.9%, much lower than its ratings for awareness and importance. For "Community rehabilitation" the awareness rate is the lowest (18.5%). This is mainly because of the simple equipment and poor service available, which is unable to meet residents' requirements for a rehabilitation service.

Since the CHCs lack the trust and support of the community, this is a real problem that needs to be solved. One has to acknowledge that deep-rooted health problems can only be solved by the people themselves in collaboration with central and local government. More emphasis should be put on the community where each neighborhood could take on a role in promoting and improving their own health care according to their own needs; an example could be taken from the U.K. model where a number of policy documents were adopted [7, 8]. The data analysis indicates that the utilization of local hospitals is very much higher than that of CHCs. This is due to the high efficiency of fiscal government departments in allocating more funds to local hospitals than to CHCs. A switch of government input into CHCs might help to ensure social health equity and efficiency in utilizing health resources.

Reforming the performance of the CHCs during the last five years has brought greater convenience to local residents and helped to serve them at different levels in medical treatment, prevention, health care, recovery, health education and family planning. Residents are accepting these services to a certain extent. However, the six main functions are not fully recognized where the CHCs' services are in reality still far from reaching their targets. They have inadequate resources, low prestige and serious lack of funding and function under difficult circumstances.

Efficient essential health care should be available to everyone. The local hospitals and the CHCs are considered the main care providers for local residents. It is important to put the six functions of the CHCs into effect and build a new and safe community health care network [1, 5].

To sum up: we need to increase the promotion of health education towards residents; try to change the residents' perception and recognition of health care; try to understand the concept of health consumption by making the CHCs' six service functions suitable for people who have high expectations and demands for appropriate health care; and make the community health service function better.