More staff, fewer patients: changes in health worker productivity in rural China

In China, sweeping economic reforms have taken place over the past two decades. Health facilities now rely less on government funding and more on user charges to cover costs. Health managers have gained greater control over human resources. Nevertheless, the question of improving staff productivity remains a major challenge.

Reducing costs and using resources efficiently have been central to health sector reform policies since the mid-1980s. In China, fewer people are using public health facilities, despite more staff having been recruited into the health sector. What impact has changes in staff levels had on staffing efficiency, health service costs and on the utilisation of services? Researchers from the Liverpool School of Tropical Medicine, UK and China's Fudan University studied changes in the productivity of China’s rural health workers.

The researchers used data from the rural component of the National Health Service Survey (NHSS) conducted in 1993 and 1998.  Three indicators were used:  the average number of outpatient visits per doctor per day; the average number of inpatient days per doctor per day; and the average number of equivalent outpatient visits per doctor per day, using the assumption that one inpatient day is equivalent to 2.5 outpatient visits.

Research findings include:

• Average number of outpatient visits per doctor per day declined by 30 percent at county hospitals, and by over 35 percent at township health centres (THCs) between 1986 and 1994.
• The average number of inpatient days fell between 1986 and 1994.  For county hospitals the highest drop (50 percent) was in the least developed rural areas, whereas for THCs the drop was more dramatic in the relatively wealthy areas.
• At county level the average number of equivalent outpatient visits per doctor per day declined from 12.2 in 1986 to 8.5 in 1994, after which the trend continued in the relatively wealthy areas only. At THCs the decline was continuous throughout the study period, with a slight reversal from 1994 in the relatively wealthy areas.
• Among the hospitals surveyed, the average number of health personnel per county hospital in 1997 was 167 percent greater than the average number in 1992.
• Average expenditure per outpatient visit and per hospital admission rose dramatically. At the same time use of outpatient and inpatient services at THCs reduced by 26 percent and 12 percent respectively between 1986 and 1997.

The declining productivity of doctors during the 1980s and 1990s has been affected by increased recruitment of staff, some of whom may be unsuitable or unqualified; the collapse of cooperative medical schemes during the 1980s; and increasing service costs which have resulted in declining use of public health facilities. Policy implications include:

• Managers need to control their facilities' resources effectively.  This requires adequate incentives and legal rules, to both oblige them to operate services sensibly and protect them from pressure to employ people unnecessarily.
• Managers need to reduce the number of unproductive staff on their payroll.
• Effective, affordable strategies are needed to retain good staff, particularly in rural areas. Managers need training in staff recruitment and selection skills, to match the bet people to the most appropriate jobs.
• To increase service use, human resource management strategies should increase productivity and improve the quality of services.
• Other measures are needed to increase access to health services, including controlling drug prescriptions and the use of diagnostic tests, and increasing insurance coverage or finding a viable alternative to health insurance.

Source(s):
‘Changing medical doctor productivity and its affecting factors in rural China’, International Journal of Health Planning and Management 19: 101-111, by T. Santos, Y Gong and S Tang, 2004

Funded by: UK Department for International Development

id21 Research Highlight: 10 May 2005

Further Information:
Shenglan Tang
Liverpool School of Tropical Medicine
Pembroke Place
Liverpool L3 5QA
UK

Contact the contributor: stang@liv.ac.uk

Liverpool School of Tropical Medicine (LSTM), UK

Fudan University, China

Other related links:
'Motivating rural health workers in north Viet Nam'

'Beating depression - innovations in Chilean mental health care'

'Where there is no regulator'

'Class act – IMCI training boosts health workers’ performance'

'Comparing institutional performance to inform health policy: evidence from Mexico'

'Paying the price? Reforming China’s public health institutions'

See id21's collection of links relevant to health systems and economics.