Health resource allocation in Western China from 2014 to 2018

This study analysed the equity of bed, physician and nurse allocation in Western China from 2014-2018 by using the Lorenz curve, Gini coefficient and Theil index. The study found that health resource allocation in Western China was still inequitable in the population and geographic dimensions, and the inequity of health resource allocation in the geographic dimension showed a tendency to worsen. The inequitable allocation of health resources in Western China mainly came from the inequitable allocation of resources within provinces. Among them, the allocation of doctors and nurses is the most inequitable.

During 2014-2018, the number of beds, physicians and registered nurses in Western China showed an increasing trend. This indicates that the Chinese government measures have been effective in increasing health resources in Western China. The main purpose of the China's 13th Five-Year Plan for Health and Wellness (13th Five-Year Plan) is to plan the development of Chinese health services from 2015-2020, so the goals of the 13th Five-Year Plan are still applicable to the period of this study (2014-2018). The 13th Five-Year Plan states that the number of beds in medical institutions per 1,000 people should be 6, the number of physicians should be 2.5, and the number of nurses should be 3.14 in 2020 [28]. In 2018, the number of medical beds per 1,000 population in Western China basically met the planning expectations, except in Guangxi and Tibet. Only Shanxi, Qinghai, Ningxia, Xinjiang and Inner Mongolia met the number of physicians per 1,000 population as expected in the 13th Five-Year Plan. The distribution of nurses is even more serious, with only Shaanxi and Ningxia Provinces having more than 3.16 nurses per 1,000 people. Thus, considering the goals of the 13th Five-Year Plan, further improvement is still needed. It is recommended that the government strengthen its role in allocating health resources, enhance the feasibility of policies, strengthen relevant safeguard measures, ensure the implementation of relevant policies to improve the total amount of health resources in Western China, and further realize the goal of "health equity for all", which is emphasized in the 13th Five-Year Plan and the Outline of the Healthy China 2030 Plan [29].

The results showed that the equity of health resource allocation in Western China was higher in the population dimension than under the geographic dimension, which may be because the current health resource allocation approach adopted in China is mainly based on population density [30, 31]. The results also show that the inequity of health resource allocation under the geographic dimension is increasing. This may be due to the complex geography of Western China, which has large geographical areas, high altitude, low population density (such as Xinjiang, Inner Mongolia and Tibet) and mostly mountains that make traffic difficult (such as Guangxi, Guizhou and Chongqing). The World Health Organization (WHO) recommends that everyone should have access to affordable, quality health care. However, the less equitable geographic distribution in Western China will lead to low access to services and low utilization of resources, which is inconsistent with the WHO's goal of universal health coverage and affects the health equity of the population [32]. The government must therefore improve the accessibility of health resources in Western China through a variety of approaches, such as hierarchical diagnosis and treatment systems, medical treatment alliances, and increased financial investment, to ensure people receive health resources timely and effectively [33,34,35].

Geographic information systems can also be used to support the allocation of health resources and further improve the accessibility of health resources. In addition, due to the geographical characteristics of Western China, it is not economically efficient to rely only on investment in equipment and capital to improve the accessibility of health resources. Therefore, the government can consider drawing on the experience of other countries, such as the United States and Japan, to establish internet hospitals and provide online consultations as a way to improve the accessibility of health resources.

The results of the Theil index analysis indicated that the inequality of resource allocation was mainly caused by the unequal distribution of health resources within the provinces. This may be caused by China’s current resource allocation policies, and the different population densities in different cities can be one of the reasons. The unique geography of Western China exacerbates inequity in allocation. Some Western rural areas have extremely inconvenient transportation and are unreachable by vehicle, which is inconvenient for the construction and transportation of health resources. Moreover, health resource allocation is related to economic development [34], and the level of economic development among cities and counties can lead to the unequal distribution of health resources within provinces. Therefore, when formulating regional development plans, the government should consider the economic strength of different regions and make targeted policies to reduce the inequity in human resource allocation caused by economic reasons.

We found that inequity in the intergroup distribution of human resources (physicians and nurses) was more pronounced in the demographic and geographic dimensions, and the inequality of intergroup allocation of physicians tended to increase in the demographic dimension. This phenomenon may be caused by the following reasons. First, the incentive system for primary care physicians, such as salary and promotion, is inadequate, which results in a lower willingness of physicians to work in township medical institutions. Physicians have a greater willingness to work in developed cities and large medical institutions, which leads to a greater difference in the allocation of human resources between urban and rural areas [36, 37]. Second, Yunnan and Tibet are located at higher altitudes and are oxygen-deprived, making it more difficult for physicians and nurses to adapt. Third, township medical institutions are usually located in rural areas, and most rural areas are ethnic minority areas that have a strong traditional culture and are more backward in economic conditions and working environment. These factors make it harder for physicians and nurses to integrate into these areas and gain a sense of identity and belonging, which limits the introduction of professional talent and makes human resources unequally distributed within provinces. Therefore, the government should optimize the practice environment, strengthen incentive mechanisms, widen promotion channels, encourage more physicians and nurses to work in township medical institutions, pay attention to humanistic care for physicians and nurses, and help them integrate into local life to ultimately improve the equity of human resource allocation.

Most previous studies of resource allocation in China have focused on the whole country or a specific province or city, but few studies have paid attention to one region. In addition, health resources in Western China are poorer than those in Eastern and Central China, and the inequity problem of Western China may be more prominent, but few studies have investigated the issue. Therefore, this study supplements the analysis of health resource allocation in Western China and provides a reference for policy makers in the Chinese government. In addition, after the COVID-19 outbreak in late 2019, the different COVID-19 prevalence and the different medical needs in each province may lead the changes of health resource allocation and researchers may start to think about how to optimize health resource allocation in Western China during the epidemic period and post-epidemic period. This study can provide preliminary data and a research basis for their future studies.

However, the present study has several limitations. First, based on the 13th Five-Year Plan, the indexes of the medical and health service system also include the number of general physicians and the proportion of beds in socially run hospitals in the total number of hospital beds. In addition, the efficiency of health resource use is a key factor affecting health equity and the capacity of medical institutions to provide services [37]. However, due to the limited availability and integrity of the data collected, the above problems were not further analysed in this paper. Second, medical needs refer to whether people can easily access the health services they need and are able to pay for them. The satisfaction of this need is one of the indicators of the accessibility of health resources [38, 39]. Although this study found a gradual improvement in the equity of health resource allocation in Western China from 2014 to 2018, it is not yet possible to measure improvements in medical needs based on the methodology used in this study and the data currently available.

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