Overall rationale for developing the metrics

Based on the findings from the literature review and conceptual discussions in Chapter 2, the two domains of functional and structural balance between primary and hospital care were established. Under each domain, sub-domains were developed, with corresponding indicators chosen for each sub-domain. The structural domain concerned with human capital and physical capital, each comprising an independent sub-domain. The functional domain concerned with service utilisation and financing, each comprising an independent sub-domain. The criteria for selecting indicators were that the indicators could reflect the nature of sub-domains and were available for

sufficiently long periods to allow meaningful analysis over time. The process of selection was iterative and resulted in multiple indicators under each of four sub-domains shown in Table 4-1. The table also shows the sources and years for which data were available.

Before getting into the details, one has to admit that no systematic measurement of the balance between hospitals and primary care providers over a long period of time can be satisfactory. First, the boundaries between hospitals and primary care providers were not always straightforward. This has been reflected in the literature review (in Section 2.3) on the various and overlapping definitions of primary care. The metrics used a level of care as the unit of analysis, zooming out and seeing primary care facilities and hospitals each as a whole, rather than zooming in and focusing on the margins of care. However, there could still be multiple approaches to operationalize the boundaries between the two levels of care. What the analysis needed to achieve was a feasible measurement with policy implications.

Second, besides the issue of debatable boundaries, both primary care providers and hospitals involved a complex range of facilities. By categorizing these facilities into two sectors the variation within each category was lost. Furthermore, the value of each indicator would also be affected by the changing availability of data. Hence, the analysis included data on sub-groups of facilities when possible to allow greater flexibility and to capture some important details.

Third, in relation to the debatable boundaries between hospitals and primary care providers, there was an inherent challenge related to the coexistence of similarities and differences between hospitals and primary care providers in the context of China, in terms of both the resources they utilised and the services they delivered. These similarities and differences challenged quantification of various dimensions of the balance between hospitals and primary care providers. As mentioned earlier, primary

care facilities and hospitals provided a significantly overlapping range of services.

While primary care facilities provided inpatient services, hospitals provided a large proportion of ambulatory care. On the other hand, there were also quite substantial differences between the two sectors. Hospitals provided to a greater extent inpatient services and used technologies (including devices) much more intensively. Even for similar categories of services, medical treatment provided in different types of facilities was of a potentially very different nature. While some indicators may be less specific to one type of facility (e.g. financial resources), others would unavoidably be more so (e.g. beds), owing to the different nature of facilities at different levels of care.

However, without a detailed look at these less generic indicators across different levels of care, one would lose the ability to appreciate fully the various details and dimensions of the balance between them.

Fourth, the temporal dimension also influences both the mixture of resources and functions and the composition of facilities themselves. While developing the indicators systematically, the study also tried to reflect the issue of the balance between hospitals and primary care providers comprehensively in the historical context of China. When considered appropriate, the study used multiple indicators for one sub-domain, as well as multiple ways of measuring one indicator occasionally, though this did not solve all issues. However, simply making the measurement more flexible and complicated could not solve all the issues. While a marginal analysis might generate useful information for short-term policy modification and resource planning, it would not allow the analysis of overall structure and functional balance needed to understand an entire level of care. As the margins changed all the time, a narrow focus on marginal areas would fragment the analysis and make it difficult if not impossible to appreciate the long-term evolution of the health delivery system. A further problem about measuring the balance between the primary care providers and hospitals over a long time was the lack of continuous reporting of data, particularly in the earlier periods.

Fifth, the diversity of China means that any measurement at national level has little to say about local situations. The huge variations between coastal and western landlocked areas and between urban and rural areas would be inevitably missed in measurement at the national level.

The next sub-section concerns the methodological issues related to the data used in this chapter.

4.3.2 Data

All data used in this chapter came from official sources and were at national level.

Data sources consisted of Health Statistics information in China 1949-1988, the statistical sections of China Health Yearbooks (published annually from 1983 to 2008—when the collection of the series ended), China Health Statistical Yearbooks (published annually from 2003 to 2012), and China Health and Family Planning Statistical Yearbooks (published in 2013 and 2014). All these sources were published by the Ministry of Health (National Health and Family Planning Commission). As the data were officially collected and reported, the way of reporting seemed to have been influenced by the historical changes of policies (and the emphases of policies during particular periods). The changes affected the availability of data and influenced the selection of indicators as well as reporting of their values. Two issues were particularly of concern.

One issue concerned the changes in the items of data reported. This sub-study covered 64 years of dynamic changes in China’s health system. The Ministry of Health (and the later National Health and Family Planning Commission) did not collect and report all indicators for all years. For instance, financial information of health facilities was rarely reported (and in an inconsistent way when reported at all) before 2004.

When necessary, substitute indicators for earlier periods were used along with necessary cut-offs between periods to make comparisons meaningful.

Another issue concerned the selection of types of facilities for reporting under primary care facilities. This issue was related to the pluralistic nature of health facilities in China mentioned above, as well as changes in categorization and reporting. As Section 4.2 has mentioned, the official term for primary care providers did not appear in national statistical reports until well into the first decade of the 21^st Century.

Therefore, the study here reconstructed the total number of primary care facilities based on reports about a range of providers that were retrospectively identified as primary care providers. As not all items of statistics were available for all types of facilities in all years, both the total of primary care facilities and their breakdown provide useful information and were included as much as possible. As the total information in earlier years were constructed by summing up available types of primary care facilities, a break sign (“//”) is added to the series with changed composition of types of facilities and indicate where the changes of composition take place. These issues are revisited in the interpretation of results in Section 4.4.

A third issue was that indicators need to reflect the development of the quality of health system resources. For example, the indicators of quality of human resources needed to reflect the significant improvement of educational level between 1949 and 2013.

The original data came in various forms: paper-based books, electronic books, on-line documents, scanned images, and Excel spreadsheets. Data were entered into a Microsoft 2013 Excel document and checked by the author with assistance from two Chinese master students in public health at Peking University. When data were available for the indicators for the specific types of facilities, they were directly harvested. However, as reporting about certain categories of facilities changed, original data of separated items were aggregated. Simulated values were used on one occasion, which will be noted in the results section.