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 tohealth sector reform policies since the mid-1980s. In China, fewer people areusing public health facilities, despite more staff having been recruited intothe health sector. What impact has changes in staff levels had on staffingefficiency, 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 ofChina’s rural health workers.

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

Research findings include:

• Average number of outpatientvisits per doctor per day declined by 30 percent at county hospitals, and byover 35 percent at township health centres (THCs)between 1986 and 1994.
• The average number of inpatientdays fell between 1986 and 1994.  For countyhospitals the highest drop (50 percent) was in the least developed rural areas,whereas for THCs the drop was more dramatic in therelatively wealthy areas.
• At county level the averagenumber of equivalent outpatient visits per doctor per day declined from 12.2 in1986 to 8.5 in 1994, after which the trend continued in the relatively wealthyareas only. At THCs the decline was continuousthroughout the study period, with a slight reversal from 1994 in the relativelywealthy areas.
• Among the hospitals surveyed,the average number of health personnel per county hospital in 1997 was 167percent greater than the average number in 1992.
• Average expenditure peroutpatient visit and per hospital admission rose dramatically. At the same timeuse of outpatient and inpatient services at THCsreduced by 26 percent and 12 percent respectively between 1986 and 1997.

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

• Managers need to control theirfacilities' resources effectively.  Thisrequires adequate incentives and legal rules, to both oblige them to operateservices sensibly and protect them from pressure to employ peopleunnecessarily.
• Managers need to reduce thenumber of unproductive staff on their payroll.
• Effective, affordablestrategies are needed to retain good staff, particularly in rural areas. Managersneed training in staff recruitment and selection skills, to match the bet peopleto the most appropriate jobs.
• To increase service use, humanresource management strategies should increase productivity and improve thequality of services.
• Other measures are needed toincrease access to health services, including controlling drug prescriptionsand the use of diagnostic tests, and increasing insurance coverage or finding aviable alternative to health insurance.