Satisfaction of Township Hospitals Health Workers on How They Are Paid in China

Background: Township Hospitals (THs) are crucial providers in China’s primary health delivery system. Low job satisfaction of THs health workers has been one of biggest challenges to strengthening the health system in China. Even huge amounts of studies confirmed low remuneration level as a key demotivating factor though few studies have explored the feelings of health workers on how they were paid. Objective: To analyze how the key design of Performance-based Salary System (PBS) influences the satisfaction of health workers on the payment system in China’s THs. Method: A cross-sectional study was conducted in 47 THs in Shandong China, and a total of 1136 participants were recruited. Expectancy theory was applied to design the measurements on designs of PBS. The associations between PBS design and satisfaction of health workers were analyzed by logistic regression. Results: Three key components of PBS design were all related to the satisfaction of health workers. Those health workers who were aware of assessment methods were more likely to be satisfied with how they were paid (OR = 2.44, p < 0.001) compared with those being not aware of the methods. The knowledge on personal performance was also associated with being satisfied (OR = 3.34, p < 0.001). The percentage of floating income in total income was negatively associated with the satisfaction, and one percentage point increase in floating income proportion could result in the possibility of being satisfied decreasing by 2.82% (95%CI −4.9 to −0.7, p = 0.01). Subgroup analysis found that only in those with lower value on monetary income, the negative influence of more floating income was significant. Conclusions: When policymakers or managers apply performance-related payment to incentivize certain work behavior, they should pay attention to the design details, including keeping transparency in the performance assessment criteria, clear performance feedback, and setting the proportion of the performance-related part based on the preference of health workers in certain cultural settings.

Intensive surveillance, rapid response and border collaboration for malaria elimination: China Yunnan’s ‘‘3 + 1’’strategy

Background Eliminating malaria and preventing re-establishment of malaria transmission in border areas requires universal coverage of malaria surveillance and a rapid response to any threats (i.e. malaria cues) of re-establishing transmission. Main text Strategy 1: Intensive interventions within 2.5 km-wide perimeter along the border to prevent border-spill malaria. The area within 2.5 km along the international border is the travel radius of anopheline mosquitoes. Comprehensive interventions should include: (1) proactive and passive case detection, (2) intensive vector surveillance, (3) evidence-based vector control, and (4) evidence-based preventative treatment with anti-malarial drugs. Strategy 2: Community-based malaria detection and screening of migrants and travellers in frontier townships. Un-permitted travellers cross borders frequently and present in frontier townships. Maintenance of intensified malaria surveillance should include: (1) passive malaria detection in the township hospitals, (2) seek assistance from villager leaders and health workers to monitor cross border travellers, and refer febrile patients to the township hospitals and (3) the county’s Centre for Disease Control and Prevention maintain regular proactive case detection. Strategy 3: Universal coverage of malaria surveillance to detect malaria cues. Passive detection should be consolidated into the normal health service. Health services personnel should remain vigilant to ensure universal coverage of malaria detection and react promptly to any malaria cues. Strategy + 1: Strong collaborative support with neighbouring countries. Based on the agreement between the two countries, integrated control strategies should be carried out to reduce malaria burden for both countries. There should be a clear focus on the border areas between neighbouring countries. Conclusion The 3 + 1 strategy is an experience summary of border malaria control and elimination, and then contributed to malaria elimination in Yunnan’s border areas, China. Nevertheless, Yunnan still has remaining challenges of re-establishment of malaria transmission in the border areas, and the 3 + 1 strategy should still be carried out.

Multi-level determinants of failure to receive timely and complete measles vaccinations in Southwest China: a mixed methods study

Background Measles outbreaks re-emerged in 2013–2014 in Guangxi Zhuang Autonomous Region of China, where measles immunisation coverage is high. The discrepancy between the vaccination coverage and outbreaks indicates that timeliness is crucial, yet there is limited knowledge on the health system barriers to timely vaccination. Using integrated evidence at the household, village clinic, and township hospital levels, this study aimed to identify the determinants of failure in receiving timely measles vaccinations among children in rural Guangxi. Methods A multi-stage stratified cluster sampling survey with a nested qualitative study was conducted among children aged 18–54 months in Longan, Zhaoping, Wuxuan, and Longlin counties of Guangxi from June to August 2015. The status of timely vaccinations for the first dose of measles-containing vaccine (MCV1) and the second dose of measles-containing vaccine (MCV2) was verified via vaccination certificates. Data on household-level factors were collected using structured questionnaires, whereas data on village and township-level factors were obtained through in-depth interviews and focus group discussions. Determinants of untimely measles vaccinations were identified using multilevel logistic regression models. Results A total of 1216 target children at the household level, 120 villages, and 20 township hospitals were sampled. Children were more likely to have untimely vaccination when their primary guardian had poor vaccination knowledge [MCV1, odds ratio (OR) = 1.72; MCV2, OR = 1.51], had weak confidence in vaccines (MCV1, OR = 1.28–4.58; MCV2, OR = 1.42–3.12), had few practices towards vaccination (MCV1, OR = 12.5; MCV2, OR = 3.70), or had low satisfaction with vaccination service (MCV1, OR = 2.04; MCV2, OR = 2.08). This trend was also observed in children whose village doctor was not involved in routine vaccination service (MCV1, OR = 1.85; MCV2, OR = 2.11) or whose township hospital did not provide vaccination notices (MCV1, OR = 1.64; MCV2, OR = 2.05), vaccination appointment services (MCV1, OR = 2.96; MCV2, OR = 2.74), sufficient and uniformly distributed sessions for routine vaccination (MCV1, OR = 1.28; MCV2, OR = 1.17; MCV1, OR = 2.08), or vaccination service on local market days (MCV1, OR = 2.48). Conclusions Guardians with poor knowledge, weak beliefs, and little practice towards vaccination; non-involvement of village doctors in routine vaccinations; and inconvenient vaccination services in township hospitals may affect timely measles vaccinations among children in rural China. Graphical abstract

Satisfaction of Township Hospitals Health Workers on Performance-based Salary in China

Background: Township hospitals (THs) are crucial primary health care providers in China health delivery system. Low job satisfaction of THs health workers has been one of biggest challenges to strengthening the primary health system in China. Even huge amount of studies confirming THs health workers ranked low remuneration level as one most important demotivating factor, few published studies explored the feelings of health workers on existing payment method design -- a kind of Performance-based Salary System. Objective: To analyze how key design of PBS influences the satisfaction of health workers with the intention to provide policy suggestions on how to improve the design of PBS, the motivation and performance of health workers in primary healthcare facilities. Method: This study is a cross-sectional study, conducted in 47 THs in Shandong China. A total of 1,136 PCPs were recruited in the quantitative analyses. Expectancy theory was applied to design the measurements on designs of PBS. We analyzed the associations between PBS design and satisfaction of health workers using logistic regression. Results: The three key components of PBS design were all related to the satisfaction status of health workers. Those health workers were aware of assessment methods were more likely to be satisfied with how they were paid (OR=2.44, p<0.001) compared with those being not aware of the assessment criteria and targets. The knowledge on personal performance was also associated with being satisfied with the payment methods (OR=3.34, p<0.001). The percentage of floating income in total income was negatively associated with the satisfaction, and one percentage point increase in floating income proportion could result in the possibility of feeling satisfaction decreased by 2.82% (95%CI -4.9 to -0.7, p=0.01). And when we grouped the health workers based on their value on monetary rewards, we found that only in those with lower value on monetary income, the negative influence of more floating income was significant. Conclusions: When policymakers or managers tried to apply the performance-related payment methods to incentivise certain work behavior, they should pay attention to some design details, including keeping transparency in the performance assessment criteria, clear performance feedback each health worker, and setting the proportion of performance-related income based on the preference of health workers in certain cultural setting.

Evaluation of a package of risk-based pharmaceutical and lifestyle interventions in patients with hypertension and/or diabetes in rural China: A pragmatic cluster randomised controlled trial

Background Primary prevention of cardiovascular disease (CVD) requires adequate control of hypertension and diabetes. We designed and implemented pharmaceutical and healthy lifestyle interventions for patients with diabetes and/or hypertension in rural primary care, and assessed their effectiveness at reducing severe CVD events. Methods and findings We used a pragmatic, parallel group, 2-arm, controlled, superiority, cluster trial design. We randomised 67 township hospitals in Zhejiang Province, China, to intervention (34) or control (33). A total of 31,326 participants were recruited, with 15,380 in the intervention arm and 15,946 in the control arm. Participants had no known CVD and were either patients with hypertension and a 10-year CVD risk of 20% or higher, or patients with type 2 diabetes regardless of their CVD risk. The intervention included prescription of a standardised package of medicines, individual advice on lifestyle change, and adherence support. Control was usual hypertension and diabetes care. In both arms, as usual in China, most outpatient drug costs were out of pocket. The primary outcome was severe CVD events, including coronary heart disease and stroke, during 36 months of follow-up, as recorded by the CVD surveillance system. The study was implemented between December 2013 and May 2017. A total of 13,385 (87%) and 14,745 (92%) participated in the intervention and control arms, respectively. Their mean age was 64 years, 51% were women, and 90% were farmers. Of all participants, 64% were diagnosed with hypertension with or without diabetes, and 36% were diagnosed with diabetes only. All township hospitals and participants completed the 36-month follow-up. At 36 months, there were 762 and 874 severe CVD events in the intervention and control arms, respectively, yielding a non-significant effect on CVD incidence rate (1.92 and 2.01 per 100 person-years, respectively; crude incidence rate ratio = 0.90 [95% CI: 0.74, 1.08; P = 0.259]). We observed significant, but small, differences in the change from baseline to follow-up for systolic blood pressure (−1.44 mm Hg [95% CI: −2.26, −0.62; P < 0.001]) and diastolic blood pressure (−1.29 mm Hg [95% CI: −1.77, −0.80; P < 0.001]) in the intervention arm compared to the control arm. Self-reported adherence to recommended medicines was significantly higher in the intervention arm compared with the control arm at 36 months. No safety concerns were identified. Main study limitations include all participants being informed about their high CVD risk at baseline, non-blinding of participants, and the relatively short follow-up period available for judging potential changes in rates of CVD events. Conclusions The comprehensive package of pharmaceutical and healthy lifestyle interventions did not reduce severe CVD events over 36 months. Improving health system factors such as universal coverage for the cost of essential medicines is required for successful risk-based CVD prevention programmes. Trial registration ISRCTN registry ISRCTN58988083.

A Comprehensive Evaluation of Township Hospitals in the Severely Cold Areas of China

Objective: The aims of this study are to establish an evaluation system and find the existing problems in the architectural design of township hospitals in the severely cold regions of China. Background: Due to the geographical location and economic factors, development still has some key problems, such as inadequate construction, old facilities, and backward technology, which are more prominent in the severely cold regions. Methods: First, evaluation factors have been selected and determined by literature review and on-site investigation. Evaluation rules have been determined using fuzzy membership function. Then, the analytic hierarchy process is used to determine the weights of the evaluation factors at all levels. Finally, take a township hospital as an example to calculate the comprehensive evaluation results. Results: A comprehensive evaluation index system with 28 elements and 76 factors for the township hospitals in severely cold regions including the basic health service capacity, the emergency capacity, and the climate fitness. Conclusions: The establishment of the comprehensive evaluation system of township hospitals in severely cold areas in this study aims to find out the problems through the evaluation of the existing township hospitals in the severely cold areas and provide guidance for the transformation of existing township hospitals in the severely cold areas. By comparing the scheme evaluation for building hospitals, we shall look for the optimal solution to provide reference for future development in the construction of township hospitals.

Training primary healthcare workers in China’s township hospitals: a mixed methods study

Background Primary health care (PHC) was a keystone toward achieving universal health coverage and Sustainable Development Goals (SDGs). China has made efforts to strengthen its PHC institutions. As part of such efforts, regular in-service training is crucial for primary healthcare workers (PHWs) to strengthen their knowledge and keep their skills up to date. Objective To investigate if and how the existing training arrangements influenced the competence and job satisfaction of PHWs in township hospitals (THs). Methods A mixed method approach was employed. We analyzed the associations between in-service training and competence, as well as between in-service training and job satisfaction of PHWs using logistic regression. Interviews were recorded, transcribed, and analyzed using NVivo12 to better understand the trainings and the impacts on PHWs. Results The study found that training was associated with competence for all the types of PHWs except nurses. The odds of higher competence for physicians who received long-term training were 3.60 (p < 0.01) and that of those who received both types of training was 2.40 (p < 0.01). PHWs who received short-term training had odds of higher competence significantly (OR = 1.710, p < 0.05). PHWs who received training were more satisfied than their untrained colleagues in general (OR = 1.638, p < 0.01). Specifically, physicians who received short-term training (OR = 1.916, p < 0.01) and who received both types of training (OR = 1.941, p < 0.05) had greater odds of general job satisfaction. The odds ratios (ORs) of general job satisfaction for nurses who received short-term training was 2.697 (p < 0.01), but this association was not significant for public health workers. The interview data supported these results, and revealed how training influenced competence and satisfaction. Conclusions Considering existing evidence that competence and satisfaction serve as two major determinants of health workers’ performance, to further improve PHWs’ performance, it is necessary to provide sufficient training opportunities and improve the quality of training.

Evaluating Patient Satisfaction in Township Hospitals in the Cold Regions of China

Objective This study focused on township hospitals in the cold regions of China and aimed to evaluate patient satisfaction during the medical care process. This study also discusses the correlation between patient needs and satisfaction. Background Hospitals seek to improve patient satisfaction to provide better service. However, there is a lack of existing literature on grassroots medical institutions in towns and townships, especially in cold regions. Therefore, this study aimed to examine the correlation between patient needs and the satisfaction of township hospitals in the cold regions of China. Methods First, a hierarchical task analysis method was used to build the hierarchy for patient satisfaction demands. Patients from 15 township hospitals in cold areas were subjected to semistructured interviews, and a theoretical model was proposed using the grounded theory method. Finally, each open code index was evaluated, and 270 questionnaires were issued to evaluate patient satisfaction. Results The framework for patient satisfaction demands included five dimensions: tangibles, reliability, responsiveness, assurance, and empathy. A theoretical model for patient satisfaction demands was built, and four selective codes, including “Characteristic”, “Perceived Quality”, “Loyalty Intention”, and “Environment Expectation”, were extracted. The weights of these satisfaction-influencing factors were subsequently evaluated. Conclusions This study summarizes the existing problems in a basic health service provision capacity, climate adaptability, lack of environmental design, and so on; proposes four influencing factors; establishes a patient satisfaction evaluation model; and obtains the weight of influence of each factor. These results will help provide accurate and effective suggestions for hospital management.