qualitative analysis of HXI to provide insight in the innovation processes ... researched innovations, which turn out as best practices. ... sustainability also regards continued improvement after HXI project end, although .... requires counties to bottom up, select innovations themselves, thus creating a .... answered in English.
This report is a project deliverable of the Evaluation Capacity Building project mentioned below as funded by the World Bank and Supported by the Centre for Project Supervision & Management of the National Health & Family Planning Commission of the PRC
Sustainable Rural Health Innovation Capacity Development in China Qualitative Evaluation of Health XI Deliverable for IDF Grant for Capacity Building of Evaluation of China’s Health System Reform Pilot Lead Authors: Dirk de Korne1, Joris van de Klundert1 Co-authors: Jeroen van Wijngaarden1, Fang Wang 2, Shasha Yuan2
1 Institute of Health Policy and Management, Erasmus University Rotterdam, Netherlands 2 Institute of Medical Information, Chinese Academy of Medical Sciences, Beijing, China
May 2015
Inhoud Executive Summary................................................................................................................................. 5 1.
Background ..................................................................................................................................... 8 1.1
Introduction ............................................................................................................................ 8
1.2
A Qualitative Evaluation of Health XI ...................................................................................... 9
1.3
Conceptual Framework ......................................................................................................... 10
1.4
Structure of this Report ........................................................................................................ 15
2. Methodology ..................................................................................................................................... 16
3.
2.1
Case Study Selection ............................................................................................................. 16
2.2
Interviews.............................................................................................................................. 18
2.3
Data Analysis ......................................................................................................................... 18
HXI Project Management & Supervision....................................................................................... 19 3.1
Introduction .......................................................................................................................... 19
3.2
Preparation & Design ............................................................................................................ 19
3.3
Alignment with National Health Reform .............................................................................. 24
3.4
Mandatory Innovation .......................................................................................................... 26
3.5
Tightly managed bottom up and top down processes ......................................................... 28
3.6
Expert guidance .................................................................................................................... 29
3.7
Incentives: Carrot & Stick ...................................................................................................... 32
3.8
Evaluation ............................................................................................................................. 34
3.8
Project Leadership ................................................................................................................ 36
3.9
Sustainability ......................................................................................................................... 37
3.10
Dissemination ....................................................................................................................... 38
3.11
Conclusions ........................................................................................................................... 40
4. Performance Based Management in Mei Xian, Shaanxi ................................................................... 44 4.1
Mei Xian ................................................................................................................................ 44 1
5.
6.
4.2.
Performance Based Management ........................................................................................ 44
4.3.
Two Tier Evaluation Design ................................................................................................... 48
4.4.
Alignment between the National Health Reform & HXI ....................................................... 50
4.5
Top Down Supervision & Management Control ................................................................... 51
4.7
Expert Design and Bottom-Up Adaptation ........................................................................... 54
4.8
Financial and non-financial incentives: carrot and stick ....................................................... 56
4.9
Leadership ............................................................................................................................. 58
4.10
Sustainability and dissemination: business as usual............................................................. 59
4.11
Conclusion ............................................................................................................................. 61
Comprehensive Hospital Reform in Xi Xian, Henan ...................................................................... 63 5.1
Xi Xian.................................................................................................................................... 63
5.2
ABC Hospital Payment System .............................................................................................. 63
5.3
Design and first implementation of case based payment .................................................... 66
5.4
Iterative adaptation and stakeholder involvement for the ABC system .............................. 68
5.5
Top down and Bottom Up..................................................................................................... 73
5.6
Close collaboration with a network of Experts ..................................................................... 74
5.7
Alignment of Pay-For-Performance incentives ..................................................................... 75
5.8
A New Role for the NCMS office ........................................................................................... 76
5.9
Reporting and Performance Incentive Effectiveness ............................................................ 77
5.10
Self-Evidence of Sustainability .............................................................................................. 78
5.11
Dissemination ....................................................................................................................... 79
5.12
Discussion & Conclusions ...................................................................................................... 79
Continuous improvement of public health services in Jiulongpo, Chongqing ............................. 82 6.1
Jiulongpo, Chongqing ............................................................................................................ 82
6.2
Baseline Measurement and the ‘Continuous Improvement’ Innovation ............................. 83
6.3
Public Health Service Innovations ......................................................................................... 85
6.4
Expert involvement and Training .......................................................................................... 88 2
7.
6.5
Financial incentives ............................................................................................................... 89
6.6
Consensus as a system innovation........................................................................................ 90
6.7
Engaging Leadership Style..................................................................................................... 91
6.8
Patient Centeredness & Patient Involvement ...................................................................... 92
6.9
Sustainability through Alignment with the National Health Reform .................................... 93
6.10
(Inter)national and Local Dissemination .............................................................................. 94
6.11
Conclusion ............................................................................................................................. 95
Case Study Synthesis ..................................................................................................................... 97 7.1 Introduction ................................................................................................................................ 97
8.
7.2
Readiness for Change & The Selected Innovations .............................................................. 97
7.3
Implementation, Adoption & Adaptations ........................................................................... 99
7.4
Expert Involvement ............................................................................................................. 100
7.5
Alignment with the National Health Reform ...................................................................... 101
7.6
Top Down Mechanisms and Leadership ............................................................................. 102
7.8
Horizontal Mechanisms ...................................................................................................... 103
7.9
Bottom Up Mechanisms ..................................................................................................... 104
7.10
Incentives ............................................................................................................................ 105
7.11
Data Driven ......................................................................................................................... 110
7.12
Patient involvement ............................................................................................................ 111
7.13
Sustainability & Dissemination ........................................................................................... 111
Looking ahead through the lens of qualitative analysis ............................................................. 113 8.1
Introduction ........................................................................................................................ 113
8.2
Methodological reflections ................................................................................................. 113
8.3
Policy Recommendations .................................................................................................... 117
References .......................................................................................................................................... 124 CPSM and World Bank Project reports ............................................................................................... 127 Appendix 1: Leadership definitions .................................................................................................... 130 3
Appendix 2: Case analysis of Jiulongpo County by Fudan University (2014:96-97) .......................... 134 Appendix 3: Evaluation criteria for the base salary and 70% performance-based salary in 2014 ..... 136 Appendix 4: Performance Based Evaluation in Jiulongpo .................................................................. 153 Appendix 5: Interview Protocol Pilot Counties ................................................................................... 174
4
Executive Summary The rural health reforms initiated in China around the turn of the millennium are among the largest health reforms around the globe as they are likely to affect around 800 million rural Chinese citizens, more than 10% of the global population (Liu 2004; Wagstaff et al. 2009; Chen et al. 2011). DFID, the World Bank, and the government of the People’s Republic of China together designed Project Health XI to aid the round of reforms which have been made public in April 2009. Project Health XI, henceforth referred to as HXI, stimulated and guided 40 project counties in 8 project provinces to pilot innovations in exploration of effective implementations of the reform. HXI lasted 6 years and the pilot counties cover a population of well over 20 million rural citizens. This report presents an independent qualitative analysis of HXI to provide insight in the innovation processes which have taken place over the years 2008 -2014, from the grass roots level to the HXI supervision level. It uses current scientific models of health services innovation processes, adapted to the context of rural China, and HXI:
The qualitative analysis of the determinants of successful reform explicitly takes the existing variation between the backgrounds, efforts, and achievements of different Health XI counties into account, to explain how the innovation as progressed, rather than emphasizing was has been achieved. As this analysis is a first qualitative analysis of a health reform project stimulating count specific improvement innovations in rural China, it provides valuable new insights in the process of rural health reform in China. The research focused on the project supervision and management, as well as on three best practice case studies, and provides novel insights into the intangible characteristics determining the outcomes of health reform interventions. While providing novel insights from extensive qualitative research, the strength and generalizability of the evidence also calls for caution when coming to conclusions. Further evaluation can strengthen the findings and provide important additional insights.
5
We now summarize seven main findings from the case studies, following the order of the model presented above: 1. Readiness for Change: Each of the three best practice counties was eager to start on the researched innovations, which turn out as best practices. HXI provided them a formal structure, support and tools to realize the existing ambitions. The best practice counties were ready to change. 2. Innovation is a development process: Two of the three best practice innovations were not immediately successful and required stamina and creativity to find the adaptations which yielded the aspired results. The social processes of adaptation, of continuous improvement, involving stakeholders, reaching consensus and adaptations have essentially complemented the technical innovation designs. The success of the best practices results from the development approach, not from the first design. 3. Implementation in alignment with HXI: HXI and the national health reform have reinforced each other in the best practice counties. The National Health Reform supported the county leadership to prioritize HXI and has made the sustainability of the innovations self-evident. From a grass roots perspective, HXI was naturally, sometimes even invisibly, embedded in the county health reform agenda. Moreover, the effectiveness of HXI in the three case study counties is likely to have benefitted considerably from the proximity of the starting times of the National Health Reform and Health XI. 4. Top Down versus Bottom Up Leadership: While HXI has initially been tightly controlled, it gradually loosened the control mechanisms over time. As a result it enabled provinces and counties to implement their own governance models, and develop bottom-up leadership befitting the bottom-up innovation design of HXI. County level leadership therefore has become a crucial success or fail factor. In the case studies, county level leadership has empowered local professionals and institutions in various forms to extend the bottom up approach to the grass roots level. 5. Extrinsic and Intrinsic Motivation: Each of the three case studies have made profound changes in the reimbursement system, in alignment with the national health reform. The financial incentives replaced previous reimbursement models (partly considered to be perverse) and matched well with the newly developed performance based management systems. They also aligned financial incentives at organisational and individual levels .At the individual level, the extrinsic motivation of financial incentives played a lesser role. Individuals appeared to be responsive to intrinsic motivational factors, when resonating with the values of the leaders and the design of the innovations. 6
6. Sustainability: It is likely that the implemented innovations will be sustained after HXI ends, because of their embedding the National Health Reform. As the interventions are not static but have embraced continuous improvement practices in each of the three counties, this sustainability also regards continued improvement after HXI project end, although presumably the pace of improvement may slow down. 7. Dissemination: HXI has also served as a platform for dissemination of the innovations among the participating counties. Moreover, some provincial health bureaus have actively stimulated dissemination between counties within their provinces. It is not clear yet whether this adoption by non HXI counties extends beyond the level of innovations to continuous improvement. The HXI best practices have been actively communicated through provinces and counties as well.
HXI has come to a close, the National Health Reform continues in the 2700 counties of rural China. From our analysis, it appears that the three best practice counties studied have made considerable and sustainable progress with their implementation of the National Health Reform. Moreover, the case studies demonstrate that this progress has largely depended on the HXI structures, resources and processes. This raises the question how the advancement of the National Health Reform in the many other counties and the 800 million citizens of rural China can benefit from their achievements, and more generally, from the achievements of HXI. Below we enlist recommendations for advancing the National Health Reform in rural China. The recommendations are further elaborated in Chapter 8:
I. Develop an effective support model for scaling up II. Base county selection on Readiness for Change & Improve Readiness for Change III. Further improve the effectiveness of Expert Involvement IV. Continue Alignment with the National Health Reform V. Scale Up requires Bottom-Up Processes, Reinvention and Time VI. Create Programs for Leadership Development VII. Enhance understanding of Performance Incentives VIII. Learn from Failure (not only from Success) XI. Improve the Evaluation and Evidence Base X. Support Dissemination and Advance Understanding of Effective Dissemination 7
1. Background 1.1
Introduction
The rural health reforms initiated in China around the turn of the millennium are among the largest health reforms around the globe as they are likely to affect around 800 million rural Chinese citizens, more than 10% of the global population (Liu 2004; Wagstaff et al. 2009; Chen et al. 2011). DFID, the World Bank, and the government of the People’s Republic of China together designed Project Health XI to aid the round of reforms which have been made public in April 2009. Project Health XI, henceforth referred to as HXI, stimulated and guided 40 project counties in 8 project provinces to pilot innovations in exploration of effective implementations of the reform. HXI lasted 6 years and the pilot counties cover a population of well over 20 million rural citizens. Moreover, this large scale and long term innovation project potentially guides reform implementations of China’s large rural population. This underscores the enormous impact HXI may eventually have and hence the importance of learning from the pilot experiences.
This report presents a qualitative analysis of HXI to provide insight in the innovation processes which have taken place over the years 2008 -2014, from the grass roots level to the HXI supervision level. The analysis is based on state of the art scientific understanding of health systems innovations processes. The present scientific understanding and evidence is predominantly based on system innovations in Western countries, as they have been studied most. There is broad consensus among scientists, that the successes and failures of health systems innovations are only partly explained by the structural properties of the selected innovations. In addition to the selected innovations, the contexts in which they are implemented plays an important role as a determinant of the outcomes. Moreover, the process of innovation has received much attention as determinant of success. Differences in the contexts or innovations may subtly interact to influence the outcomes, and hence need to be studied to increase the likelihood of future success of innovation (Marshall & Ovretveit 2011). This holds especially true for China’s health reform, whose contextual determinants and processes of innovations have received little attention from the international scientific community. This report provides extensive qualitative analysis into the HXI innovations, the corresponding innovation processes, and the contexts in which they have taken place, and therefore provides a significant contribution to the understanding of successful rural health reform in China. It provides an account of independent research according to international scientific standards. We hope it will 8
benefit the effectiveness of future rural health reform in China, and may a serve as a valuable source of reference for other countries as well.
1.2
A Qualitative Evaluation of Health XI
HXI involves health reform pilots in 40 counties in 8 provinces. It benefits from a World Bank loan and a DFID grant, and these parties also provide operational support to the project management, which is in the hands of the Center for Project Supervision and Management (CPSM) of the National Health and Family Planning Commission (NHFPC) of the People’s Republic of China. More specifically, HXI program is supported by a 350 M RMB loan from the World Bank and a subsidy of 70 M RMB from DFID. HXI has started in November 2008, the final conference has been held in November 2014.
The main aims of HXI have been to: 1)
Improve the rural health insurance system
2)
Increase capacity, quality and efficiency of rural health service provision, and
3)
Enhance rural public health service.
The mid-term reviews as published by CPSM and invited researchers provide a wealth of data on the achievements and an initial assessment. The many reports published at project end by CPSM and invited researchers shed further lights on the achievements, both at the project level, as well as in the various counties which participated. (When all required data is available, we will deliver a quantitative analysis of the achievements as a companion report.) Such descriptive, primarily quantitative assessment are appropriate to measure progress while the project is in operation, and to formally establish the results at project end., and for accountability reporting. As argued in the introduction however, it may fall short of providing insights in why the innovations have achieved the outcomes, or why they have failed to received them. Such insights into determinants of success and failure of innovation are often best provided through the qualitative analysis provided in this report.
A qualitative analysis of the determinants of successful reform is especially appropriate as HXI explicitly recognizes that variation exists between the backgrounds, efforts, and achievements of different Health XI counties. The qualitative analysis which provides the insights into how the design, 9
implementation and achievements varied over provinces and counties, i.e. how contexts and innovation process have differed there befits the design principles of HXI. Moreover, as HXI aims to contribute to sustainable and scalable improvement, which may also vary among the innovations of various counties. Taking all of these considerations into account, the qualitative analysis considers three case studies of three different reform innovations in three different counties, as well as an analysis of the HXI project management structures and processes. This reports doesn’t explicitly attempt to measure or assess the achievements of HXI as a whole, or of the three case studies. Instead these achievements are considered as given, and receive attention when helpful in the qualitative analysis.
As also reported in the companion literature, present scientific understanding of determinants of successful reform in China is scarce. Wagstaff et al. (2009) for instance consider the variety of sometimes contradicting results of evaluations of health system or health services innovations in China and instead of coming to generalized understanding conclude that ‘the real sources of variation lie elsewhere, perhaps in intangible characteristics of the schemes and the health facilities serving the area.’ Their findings illustrate that researchers have focused on quantitative before-after analyses, which have altogether not resulted in a well-structured evidence base, or theoretical understanding. Perhaps because the outcomes cannot be explained without taking the context and innovation processes (or as Wagstaff (2009) call it ‘the intangible characteristics) into account. Such analysis has however not been reported and therefore neither theoretical understanding nor an evidence base has been developed for health reform in rural China. In our research, we therefore set out from the basis of scientific understanding of health systems and services innovation as it has generally developed in the scientific literature, as further detailed out below. The discussion and conclusions sections provides reflections on the validity of these general theoretical concepts and evidences for China’s rural health, and on the appropriateness of the commonly applied research methods in this context.
1.3
Conceptual Framework
The conceptual framework depicted in Figure 1.1 provides the synthesis of a conceptual framework derived from scientific literature (see the companion Literature review), HXI documents, and discussion with HXI supervision management and national experts. It has been presented, discussed and adjusted during field work and evaluation workshops attended by the authors, national experts,
10
HXI management, and HXI participants in March 2014 and forms the basis for the work presented in this report.
Figure 1.1: Conceptual model of innovation
Figure 1.1 presents a conceptual model of innovation. The unit of analysis that can be studied with this conceptual model is an innovation which has taken place within one of the 40 HXI counties during the years 2008-2014 as part of the HXI implementation. As counties have implemented several innovations, the unit of analysis is therefore not the county, but an HXI innovation conducted by a county. Conducting an innovation is depicted as a cyclical process. While working on HXI, a county goes ‘full circle’ once for each innovation. If the innovation is successful and disseminated, it may raise awareness from subsequent counties, and assist them in improving their health system. This conceptual model therefore also captures spread of the innovations among HXI counties, or within provinces, or indeed within rural China at large (and in fact also across the Chinese borders.) We now consider each of the phases, or stages, in more detail.
The ‘Awareness’ phase refers to the initial recognition of a need for improvement of the existing health systems and/or services. In HXI the creation of awareness was explicitly supported by a mandatory baseline measurement and analysis, as well as attendance of HXI workshops where international and national experts presented best practices. These activities resulted in prioritizing areas for improvement, based on local needs at county level, i.e. based on the local context, resulting in a rationale for innovation. Informed by the workshops, expert interaction, and perhaps other activities such as study tours, the counties subsequently selected innovations. The importance HXI attaches to the county level contexts is again visible when counties where required to adapt the 11
designs of the innovations to their local needs. This phase is in line with scientific understanding of innovation processes, which emphasizes that especially the process of adaptation, in particular involving all relevant stakeholders, results in adoption of the innovation by these stakeholders (see. e.g. Greenhalgh et al. 2005) . This adoption is an important success factor in the subsequent stages. Subsequently, the implementation of the designed innovation starts, after which there may be one or more cycles of reporting (evaluation) and further adaptation and improvement. Notice indeed that this implies that the implementation is not a ‘single attempt’ after which the innovation an either be classified as success or failure. Instead, of a design process, successful innovations in complex social contexts is a development process, where several improvement cycles are executed before innovation is successful (see e.g. Van Aken et al. 2005). Of course, some innovations may still result in failure after several rounds of improvement. Finally, Figure 1.1 includes the topics of sustainability and spread. These topics have received considerable attention in scientific literature in general (see e.g. Rogers, 2003) for a seminal reference, and in health service improvement in particular (see e.g. Greenhalgh 2005 and the references therein) as many successfully implemented innovations are not sustained or spread. Sustainability and spread are of special interest in the conceptual framework as HXI aims to develop best practice innovations, to be spread to non-HXI counties and advance the implementation of the National Health Reform in rural China.
In addition to the phased innovation process outlined in Figure 1.1, the analyses explicitly addresses a number of determinants of successful innovation, which are hypothesized to be of particular interest for health reform in rural China, on the basis of the Literature review and sample field studies:
1. Top down versus bottom up innovation processes 2. The role of Leadership 3. Incentive mechanisms 4. Single loop versus Double loop learning
We now briefly motivate each of these hypothesized determinants of innovation effectiveness.
Top Down versus Bottom Up innovation processes are important for a two reasons. Firstly, by design HXI is essentially different from it predecessors, in which the innovations were not selected at county 12
level but by project management (e.g. World Bank and Ministry of Health). HXI however, explicitly requires counties to bottom up, select innovations themselves, thus creating a new processes of innovation, and exploring new pathways for rural health reform in China. These new pathways create a considerable shift from long standing hierarchical, top down, governance practices. Indeed, one may view that HXI in itself pilots a governance reform, which may affect the success of innovation. There is evidence that bottom up involvement is positively correlated to success of innovation in Western health services. For an important part however, this evidence stems from working cultures in which the hierarchical orientation might essentially differ from that of the working cultures in health services in rural China. Not only with respect to the relations from the county health bureau upwards to provincial and national levels, but also regarding the relations downwards to health service facility management, and health service professionals such as doctors and nurses.
As current scientific understanding points out that leadership is also an important determinant of success of innovation, we explicitly research the leadership roles at the various levels involved in the HXI innovations as well. Like governance structures, effectiveness of leadership and leadership styles is largely culturally determined, and hence deserve explicit exploration in the context of health system reform in rural China. The various levels of HXI are presented in Figure 1.2, where the most outer level is the top level, and the inner level represents the lowest level of the patients (or rural citizens) with whom the health service professionals interact.
Many of the problems which existed in the rural Chinese health system prior to HXI start, where diagnosed to be related to incentive systems. For instance the fee-for-service models and the drug prescription mark ups were considered to lead to overtreatment and over-prescription. One might hypothesize that such financial incentives play a particularly important role in the context of China’s rural health system. Especially so as both the national health reform and HXI advocated changes in the financial incentives. HXI encouraged experiments with pay-for-performance, and performance based management, where performance assessment influenced health service facility budgets as well as salaries. This is of interest from a scientific perspective, particularly so as present scientific understanding indicates that financial reward systems for personnel may also have counterintuitive effects, for instance as they negatively impact intrinsic motivation.
13
Figure 1.2: HXI stakeholders from patient to World Bank
Lastly we consider the learning, and levels of learning which accompany the innovations. As explained in the companion literature review, learning can take place at various levels. At a basic level, there is single loop learning. It refers to a learning process, in which the students, in the case of HXI the stakeholders involved at county level, learn the new structures and processes as they follow from the innovation (through a cyclic development process.) For instance, the stakeholders learn how to implement a self-developed clinical pathway for Type 2 Diabetes in which the Village Clinic and the Township Health Center collaborate. Such a single loop learning process may result in a successful innovation which greatly benefits the population, is sustained, disseminated, and adopted in many other counties in rural China. A double loop learning process now regards that counties learn how to learn single loop innovations. For instance if a county learns how to design and develop integrated care pathways for any condition, it may also address other diseases and manage over time a set of integrated care pathways addressing the most pressing health service needs of the county. The latter will happen only if the double loop learning is sustained. If double loop learning is sustained HXI not only brings forward sustainable innovations, but a sustainable capacity to innovate. A natural follow up question, is whether such sustainable innovation capacity can also be disseminated?
14
1.4
Structure of this Report
In Chapter2 we will first outline and motivate the research methods of the qualitative analysis. The subsequent Chapters 3 to 6 cover the analysis at the project management level, respectively, three innovation case studies. Chapter 7 presents a synthesis of the case studies, presented in Chapters 46, which take the project management findings presented in Chapter 3 into account. Chapter 8 provides conclusions as well methodological reflections.
15
2. Methodology 2.1
Case Study Selection
The Erasmus University research team selected three innovations in separate counties from a set of proposals made by CPSM. Each of these innovation cases was considered to be a best practice by CPSM. Hence, by study design, this research is expected to provide insight in success of innovation by exploring successful innovations. We have not attempted to scientifically assess whether these innovations have indeed been relatively successful compared to other HXI innovations. We also emphasize that the evaluation regards specific innovations, not the complete HXI performance of the respective counties.
Week of May 13
Week of May 19
Week of May 26
Performance –based
Equalization of
Comprehensive
management of rural
public health
reform of country
Project focus health facilities
services
hospital
Pilot
Meixian,
Jiulongpo,
Xixian,
Shaanxi
Chongqing
Henan
Figure 2.1 Field Research Schedule
The case studies have been conducted in May 2013 (see Figure 2.1 for a detailed schedule). Most of the interviews with (inter)national staff were done during the same period, at the working places of the respondents. The interviews with one World Bank official, a DFID representative, and a formerly involved CPSM leader took place between July and September 2014 per telephone/Skype. The interview sessions in the counties started with a general opening meeting, after which 3 days of interviewing followed, concluded by a member check session with all participants. In total, 48 interviews were conducted. A full list of respondents by function is provided in Figure 2.2. The researchers have requested to interview two respondents for each role whenever possible. The subsequent selection of respondents was done by CPSM and for the case studies, by the county health 16
bureau and CPSM together. The translators where hired via CPSM and CPSM has provided extensive operational support to organize for the requested interviews and field visits. One of the case study (Xi Xian, Henan) counties was selected on short notice, because of travel limitations for foreigners to the county of first choice (Yi Yang, Henan).
Level
Experts
Shaanxi
Chongqing
Henan
Worldbank
2
DFID
1
CPMS
4
National experts
3
Provincial level experts
2
County level experts
1
Provincial HB
1
2
1
County HB
3
4
2
County H
-
-
2
Health professional THC
-
-
2
THC management
3
3
1
Health professional VC
2
3
2
Patients (FDG)
3 (1)
10 (2)
5 (1)
12
22
15
Total
13
Figure 2.2 Respondents by function
17
2.2
Interviews
Questions were asked in English. The international respondents as well as two Chinese respondents answered in English. For most other respondents a certified translator non-simultaneously translated questions and answers. In two occasions the interview was moderated by a Chinese health services research scientist. During all interviews, there were at least two interviewers (both Ph.D.’s) present; one Dutch and one Chinese, or during one interview two Dutch interviewers. All interviews used the same topic list which covers the stages of the conceptual model presented in Figure 1 as well as the four additional items described above. The topic list with more detailed reference materials is included as Appendix 5. The prioritization of topics varied per respondent, based on role and experience. In principle, interviews were held with one respondent at a time, except for the patient interviews which took the form of focus group interviews. The interviews lasted between one and three hours. Respondents were informed that the interviews were anonymous.
2.3
Data Analysis
The English texts of the interviews were transcribed by Chinese MSc and PhD students of Erasmus University Rotterdam and Erasmus Medical Center, who resolved unclear fragments using the Chinese audio files. For each case study, and the national level analysis, the transcripts were analysed by one researchers, and discussed with a second researcher based on the original texts and analysis reports. Grammatical translation errors in the citations presented in this report were repaired by the authors. The analysis of the transcripts was added by document analysis of presentations, case study reports, and formal HXI reporting documents, both in English and Chinese. Translation and discussion of the documents was done with a Chinese MSc researcher.
The initial case studies reports where subsequently synthesized and aligned with the national level synthesis, thus leading to further adjustments and alignment in the presentation of the findings.
Chapter 8 includes a separate reflection and discussion of the research methods.
18
3.
HXI Project Management & Supervision
3.1
Introduction
This Chapter reports on the findings of interviews with international and national staff and experts involved in HXI. It regards the project design and management and provides insight in how the project came to existence and has been operated. The purpose is to understand how HXI has taken shape and how it has been executed, especially in relation to the present scientific understanding which has shaped the conceptual model. Moreover, we consider how the project design and management has contributed to sustainability and scale up. A discussion of the findings and practical recommendations will be presented after providing the results.
3.2
Preparation & Design
The preparation of project Health XI started as early as 2005, while project Health 8 (henceforth HVIII) was approaching its final years. It started in an era of reflection on China’s rural health system and subsequent ambition and activity for improvement. We start by providing the background information on the Chinese health system and reform priorities during those preparation years, and then continue with an account of the preparations.
In the early years of the new millennium, China’s rural health system left much to be desired for the rural population, of which many were poor farmers. The WHO ranked China 188th out of 191 on fairness of financial distribution (WHO, 2000) and ranked China 144th on overall health system performance. As much as 96% of rural households in China lacked medical insurance in 2003 (Wang 2009). Moreover, 38% of the sick did not seek medical attention, and medical debt forced many households to reduce food consumption. Illness had become a leading cause of poverty in rural areas (ibid.), potentially further increasing inequities. Yip and Hsiao (2008) point out that the private and public health service organisations typically depended for at least 90% of their revenue on fee for service models as well as kickbacks (and bonuses) from medicine prescriptions, which were paid out of pocket by the uninsured rural population. This dependence is viewed as a cause for supply induced health services. Wagstaff et al. (2009) cite evidence for ‘extensive overprovisioning of care’, as for instance illustrated by the high Caesarean section rates, and refer to a publication which describes 19
‘less than 2% of drug prescriptions as rational. Public health and preventive services were receiving little attention. While the national figures on the health system in the People’s Republic of China have been classified as ‘impressive’ by the World Bank (2005), they conclude that “gross health statistics have masked the near crisis in the poorer rural areas. Devolution of financial responsibilities as part of the fiscal reforms accompanying the transition to the market economy has been a major factor. Without external infusion of funds, these lagging regions are too poor to provide adequate levels of essential health services and preventative care.” The analysis also reveals that for earlier World Bank contributions “the bulk of project activities take place at county levels and below, obligating participating counties to bear the repayment costs of the credit. Poor counties cannot participate because they lack the means to provide counterpart funds and to repay the credit with interest. Ironically these counties had poor health because they had lacked the financial and manpower resources to provide what was needed in the first place.” In the same report the World bank concludes that collaboration with DFID had been effective in “lessening the loan burden for poor communities”.
Against this backdrop of events and viewpoints in the year 2005, the Chinese government, more specifically the Ministry of Health (MoH, now National Health and Family Planning Commission, NHFPC), Worldbank and DFID agreed to design HXI to lead further rural health reform while placing much emphasis on the county level. From the Chinese side, this also involved cooperation with the Ministry of Finance (MoF) and the National Development & Reform Commission (NDRC). Health XI was designed at the time where there was a serious national level policy debate on China’s health sector reform, whether China needs a comprehensive, systematic, big health sector reform; what should be the policy. (Respondent N5) The debate mentioned by the respondent and the considerations and design for ‘big health sector reforms’ yielded the project preparations to be more difficult than anticipated, and to take more time than expected. Despite the shared willingness, the lack of agreed reform objectives and uncertainties about future policies created room for differences in priorities among the three stakeholders: World Bank, DFID and the Chines government. In fact, the Chines governmental institutions involved also had different viewpoints on project aims and priorities. Actually, HXI was prepared for many years before 2008. But due to the Ministry of Finance and National Development and Reform Commission, these ministries have different priorities and concerns, the Ministry of Health, Ministry of Finance, 20
and National Development and Reform Commission cannot reach consensus on the project design. So it took too many years to get the consensus. (Respondent N1) The differences in priorities also arose as for instance DFID and NDRC prioritized the poorest, while MoF was of the opinion that richer rural counties were likely to be more effective as pilots. Moreover, whereas some stakeholders intended to emphasize the reform implementation capabilities of the counties, others, such as NDRC prioritized building infrastructures. As consensus on these topics developed, a discussion of the measures; the indicators, arose. The World Bank proposed using internationally standardized performance indicators, but Chinese stakeholders did not consider each of these indicators to be reform priorities. The final design reflected the various viewpoints and consensus reached: Because the World Bank wants to focus on the poor, but at the same time poor counties often don’t have the capacity of richer counties. So I think we blended the relative rich and relatively poor counties. Probably that was good that the poor counties could learn from richer counties because they moved more quickly. (Respondent N4)
The drafted project was financed by a subsidy from DFID for capacity building and a loan from the World Bank for infrastructure as well as capacity building (50/50). It included counties from poorer (Western) provinces as well as from more developed (Eastern) provinces. The final consensus entailed to involve 8 provinces and 40 counties. The loan was largely covered at the national level, to prevent financial difficulties for poor counties, and provinces covered 15% to over 30% based on their financial capability. The national level responsibility for the loan was an innovative feature of HXI, which also delayed project approval.
Following the aforementioned policy debates, the national health reform which was being discussed, was considered to address a diverse number of issues. For ease of reference and understanding, we now enlist the 5 components of the national health reform as eventually made public in 2009, but unknown during the HXI design stages:
1.
accelerating the establishment of the basic medical security system;
2.
establishing a national essential medicines system;
3.
strengthening health services at grass roots level;
4.
promoting the equalization of basic public health services; and 21
5.
promoting pilot projects for public hospital reform
Although not explicitly available, the rough outlines of the reform have informed the design of HXI, which aimed to lead the rural health reform. Not only, was HXI therefore broadly scoped to address problems in different aspects of the health system, ranging from insurance, to service delivery, to public health, it was also designed to consider the interrelationships between them. A key characteristic of HXI is that is strives to be ‘comprehensive’. The comprehensiveness firstly follows from the HXI design, which explicitly defines the following four components (CPSM, 2008):
1. Insurance coverage and provider payment 2. Health Service Delivery (at village, township and county level) 3. Public Health & Prevention 4. Project Management
The insurance component explicitly addressed equity by (‘comprehensively’) considering the linkages between NCMS, Medical Financial Assistance (MFA) and (funds for) catastrophic health expenditures. The comprehensiveness may also refer to addressing the interrelationships between these components, for example provider payment innovations may intend to improve health service delivery. Moreover, as explicit through components 2 and 3, HXI targeted both preventive and treatment services, and at various levels, for instance via the Village Clinics (VCs), the Township Health Centers (THCs), and the county hospitals (CHs). Moreover the management of HXI was also designed to encompass innovations. As the project aimed to build the problem solving capacities of counties, instead of capacity for implementing prescribed solutions, the project needed new methods of management control to facilitate counties to effectively shape their own comprehensive innovations. In other words, the project design explicitly intended to build capacity for bottom up, as opposed to top down, innovations. Component 4 addressed the corresponding project management methods for all involved.
The alignment with the National Health Reform is further elaborated as a separate topic below. For now we conclude by mentioning that many respondents spoke of the preparation phase using words such as ‘very long’, ‘complex’, ‘delay’. At the same time respondents univocally spoke positively about
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the design qualifying it as ‘good’, ’robust’, ‘excellent’, and viewed the HXI design as a key success factor. If people said HXI is successful, I think the main reason should be the good design of the proposal. Because the major components were almost highly consistent with the rural health reform issued later on. (Respondent N1) I found HXI to be well designed. It was a very innovative project. It allows a mix of traditional procurement methods with some new innovative approaches in terms of disbursement. (Respondent N4) The selection of counties and provinces to participate in HXI has been a complex design decision. In the end, four more developed provinces (Eastern provinces) and four poorer provinces (Western) provinces were selected, each of which could select five counties. The provinces received selection criteria from (CPSM) to this purpose. Still, quite some variety in county selection was observed, as provinces came to different interpretations or additional criteria. Some counties were selected for demonstrated capabilities in earlier World Bank projects, others because they were considered to benefit most from participating. Some counties volunteered and lobbied to be accepted, others had little choice. As a result, there were differences in capability and motivation, which was not valued equally positive by all involved, and is believed to have affected the Health XI achievements. In the previous projects, the counties were already told what to do and how to do it. They just followed orders. But for our project, HXI, they had to figure out how to improve themselves. For this kind of project, the selection criteria should be very different. (Respondent N2) So when the provinces selected the counties, they also assumed that we can give them some money for the hardware construction or support for these counties. So the selection was not based on the capability of doing things or the will of doing this project. Some counties in the 40 counties were not successful in the project, because they still followed the old way of doing things. They would just wait for the instruction from the top level and follow what was done by other pioneer counties. So they are left in this project. This also affects the success of the project. It is not only a county selection issue, but also for the selection of the provinces. The provincial level has also an important role in our project. For some selected provinces, they aren't very willing or enthusiastic to do this project and throughout this project they didn't recognize their positions accurately. This affects the result and that’s why the counties in such provinces are left behind in the whole project (Respondent N6)
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The commitment and support of county level leaders, such as the mayor, and other county level stakeholders which are not under the control of the county health bureaus proved to be important. For instance the roles of the county finance office, civic affairs, has been significant, as well as the county level decisions to provide adequate human resources. These matters could not be managed hierarchically via national levels (NHFPC) or the provincial health bureau. Sometimes there is no health bureau chief at the county and the county mayor doesn't send any personnel to the county project office. The provincial office cannot do anything about that. So it affected the implementation of the project. (Respondent N10)
Indeed some respondents indicated that the design was not comprehensive enough in its formal inclusion of county level stakeholders
The legal documents of the project were signed on May 12, 2008; the project kick-off meeting was held on October 20, 2008 in Beijing; the project was brought into operation at the end of 2008; all project proposals of eight provinces and 40 counties were approved on June 12, 2009, marking the full start-up of the project (CPSM, 2011).
3.3
Alignment with National Health Reform
As can be inferred from the above, the design of HXI coincided with the design of the national health reform. The design decisions of HXI proved to be more complex than some had anticipated and caused it to take more time. While the HXI preparations thus lengthened, the Chinese government gave increasing priority to the national health reform, which was eventually announced on April 7, 2009 (see e..g Chen, 2009), earlier than some anticipated. The HXI design was influenced by the information provided on the design and the timing of the national health reform, which lead to subsequent adjustments in the HXI design.
The adjustments have also been made as it became clear that HXI was not going to deliver results in time to inform the (design of the ) national health reform as initially intended. Respondents indicated that this affected the position of HXI in relation to the National Health Reform. Rather than informing the design of the National Health Reform, the role became to create best practices, leading the way 24
for non-project counties as well: ‘The project provided a vast testing area for national health reform’ (CPSM 2011). In this situation we changed the position of this project to provide some contribution and innovation to the implementation of the national health reform policy in the counties. Generally speaking, our project has played such a role. When the health reform policy was propagated, some counties didn’t know how to implement it. So we have conducted some innovations about it in the project counties and got some inspirations. Then other regions would study it and learn from it. So HXI really played a role in piloting the implementation of the national health reform and the pilot counties played a role in the innovation. We innovated some practices and then other counties can study. (Respondent N7)
While we will see through the case studies presented in Chapters 4-6 that the overlap in time of HXI and the national health reform, has played a forceful role in the innovations, at times it also caused difficulties. The national health reform rendered some of the HXI activities to become irrelevant. For instance it provided details on the public health service package, thus eliminating an area for exploration. This details of the national health reform have therefore led to adjustment of the HXI project design during the initial project activities. So in the early days of the project, as national experts, we actually felt confused as to how to proceed because the situation had changed. The direct question was: Now the national reform has been introduced, what do we innovate? (Respondent N2) But by the time the project got on board, was approved and implemented, the Chinese government had come up with the national plan. So the project was fitted under the national reform umbrella. That seemed to constrain the project a little bit. But at the same time it also gave guidance to the counties…..which I think was very important. (Respondent N4)
Many respondents confirm that the design of HXI was adjusted, so that the national health reform served as a framework which helped Health XI to gain shape, and clarified some of the issues participants had been struggling with. As will become clear in Chapters 4-6, the eventual alignment was such that county staff involved often didn’t distinguish implementation of HXI from implementation of the national health reform. This evidences the close alignment of Health XI with the national health reform. This alignment has also helped HXI counties to receive award for their achievements with the national health reform. 25
From an evaluation perspective we note while that the overlap in execution period and alignment may have benefitted the achievements, it becomes more difficult to attribute achievements to HXI.
3.4
Mandatory Innovation
HXI recognized that a variety of different reform priorities may exist among the 40 participating counties (henceforth referred to as HXI counties). Hence, each of the HXI counties was asked to set their own priorities using baseline measurements (partly based on the National Household Survey), and the formulated Health XI set of 22 indicators. Within the four HXI components, the counties were subsequently expected to design, plan, and implement their innovations. (In the remainder we will sometimes also refer to them as ‘interventions’). This bottom up process differed considerably from previous World Bank projects, and from standing practice in the Chinese health sector. In fact, the bottom up innovative nature of HXI forms a disruptive innovation in itself, which involved an ‘adoption’ process of the participants, even referred to as a ‘transformation of the mindset’. HXI is not like other health projects. Take for example HX, in which all counties implemented the same things such as diagnosis, treatment and X-ray for TB control. Every county did the same thing. But for HXI, we only have the framework for each component. It is like a circle, within the circle, the county has its freedom to select what pilot experiments it is going to do, based on its own situation, background and health status. (Respondent N1) First, we focused on transforming the mindset of the Project Management Office and the County Health Bureaus and also the health care system people. We told them why we needed to do this and why we should conduct the reform. We also asked them to see how to do this. Then the local people understood why to do this and really got started to do it after they got this kind of ideas. This is the first phase, which is the transformation of their mindset. (Respondent N7) Until HXI, reform took shape via top down implementation of prescribed innovations. HXI, however asked creativity and problem solving capabilities from the HXI countries from the beginning. The HXI project management organized capacity building workshops, demonstrating international best practices, explaining the components, and reporting requirements. Still, the counties had great difficulty to creatively design innovations and produce their own corresponding implementation plans. For the innovation, a lot of counties were facing great challenges because they didn’t know how to do it. This is also one of the challenges when you do 26
innovations in China. We originally only got the general objective of the project and knew the components, but we didn’t have a guideline on how to do it. The project counties found it quite challenging to draft proposals. At the very beginning the quality of the proposals was quite uneven. Some counties understood the project well and delivered quite good proposals, so they didn’t need many revisions. But some others did. (Respondent N6) As an intermediary step, it was decided that just six counties would prepare their plans first, with the help of a panel of the national experts. (The role of these and other experts will be explicitly elaborated below). The six innovation plans were subsequently shown as best practices to the 34 other counties, in the first half of 2009. At that time additional information on the national health reform came out as well. This helped all counties to present innovation plans by mid 2009 (CPSM, 2009). Still, not all of these plans were viewed to be equally ambitious, or equally creative. The first batch included 6 counties. At that time we launched numerous meetings to help them on every step, such as how to write the proposals and how to write the activity plans……..and then after the national reform came out, we changed the initiation by batch to initiation as soon as possible. (Respondent N3) The struggle of HXI to develop plans and be in control over their successful implementation was perhaps most explicit in the first half year of HXI. Several respondents however, indicated that the first two years have been a period full of learning and difficulties. The aforementioned ‘transformation of the mindset’, accepting the responsibility over county level improvement by county health bureaus, and creating the first successes, took considerable effort and time. When the transformation of mindset advanced, behaviours changed, and progress sped up. At the beginning of the project, during our training, the county people were very quiet and even the provincial people. They didn’t ask anything. But as the project progressed, whenever we had a training or seminar, the county and provincial people became active in expressing their comments and views. They were very confident. (Respondent N1) Respondents have considered these general changes in attitudes and capabilities as the most valuable outcomes of the project. Not the successful completion of a specific innovation, such as pay for performance, clinical pathway implementation or the composition of an extensive Public Health package, but the county level capacity, or bottom up capacity, to find solutions for the problems prioritized by a county itself. The general ability for cyclical improvement: define a problem, measure, analyse, design and implement a solution, evaluate, and repeat.
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3.5
Tightly managed bottom up and top down processes
Although in comparison to its predecessors, HXI discontinued the practice of prescribing interventions top down, it still involved forms of top down management practices. The top down processes may in fact have been more challenging than before, as they interacted with and depended on novel bottom up processes. To manage the corresponding risks and ensure due progress, HXI implemented new management practices which took shape in a tight and detailed supervision structure. First; all plans by the counties were submitted to provincial project management offices, where they received feedback from provincial health bureau staff and provincial experts. Then the counties were asked to revise the plans until approval by the provincial level. Subsequently the plans were submitted to the national level, CPSM. CPSM asked a panel of 14 national experts (NEXs) to review the proposals. The feedback was presented to the provinces, who took care of processing the feedback. After one or several rounds of feedback by the national experts, the plans were considered by CPSM for approval and submission to the World Bank. If the World Bank also approved, the plan was accepted, and funds were allocated. The plans needed to specify concrete, time-specific objectives, which would act as triggers for releasing funds. Counties were expected to report frequently on progress to their provincial project management offices (PMOs), and provide a written report to CPSM at least twice a year. Close monitoring was considered a success factor because of the complex and changing environment of the national health reform and its stakeholders: The other success factor is the real time monitoring and the collection of information. As the central level decision makers, it is important to know the opinions from every level of the project. If you don’t know the exact information from different sides, when making decisions, you will not feel confident about the decision. (Respondent N3)
Moreover, CPSM organized two national supervision and also two joint supervision meetings (joint with the World Bank) yearly. The supervision missions typically were organized in the form of visiting two counties in a same project province.
The planning and control cycle of HXI, in which detailed progress was reported twice annually, was new to all Chinese parties involved, and executed fervently by CPSM, as well as by the World Bank. Especially in the early years of the project, monitoring took place on a detailed level. In later project
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years the tight formal controls were partly replaced by ex-ante instructions on mandatory innovations, and partly delegated to the provincial level.
3.6
Expert guidance
Experts played an important role in Health XI. There were 4 ‘levels’ of experts involved: international experts, national experts, provincial experts and county experts. The interactions with international experts played a prominent role in the early stages of HXI, by exposing counties to international best practices and scientific principles. Instead of copying and pasting these practices, the domestic experts and counties were quick to ‘translate’ (Ovretveit, 2001) these practices to local, Chinese, contexts.
We combined the good experience with the Chinese condition. If we don’t do this but just directly copy, the successful cases would be quite limited. Since we have different reality and also condition from the foreign countries, if we directly copy the European experience into China, it cannot work, because China has its own conditions. Just as I mentioned, we don’t exclude the good experience, but we need to combine them and digest them and then to innovate, and finally work out the working mechanism which is more suitable for the Chinese condition. In my opinion, we have got some direct copies, but they seldom succeeded; but through the combination it is easier for us to succeed. It should be a process like this: firstly to study, and then to digest and then innovate. (Respondent N7)
The reader may note how this respondent summarizes the CIMO logic presented in Chapter 2 with application to HXI. Following the aforementioned ‘digest and innovate’ steps, the involvement of international experts played a minor role after the selection stages when counties struggled with concrete Chinese and county specific difficulties, often with a managerial flavor to it:
What the Chinese were looking for was that the international expert would give very concrete recommendations. The Chinese are very practical people. They are very ambitious and wanted to get things done. The consultants we brought in were often brilliant but they found them to be less concrete about what to do next. So they were not always enamoured with the recommendations they gave. 29
(Respondent N4)
….international experts, they usually had very limited knowledge about the Chinese context. … They are focused on the technical issues. But these are obviously not the focus of our project. What we are doing is not to see if what they are doing is according to technical specifications. We are interested in management policy. (Respondent N2)
The national experts played an important role throughout the project, which we will detail out below, and reconsider extensively in the three presented case studies. The provincial and county level experts often joined forces with the county project management offices to advance the innovations. The provincial experts often acting as a second line help desk when the typically part time county experts requested assistance.
There is another group of experts at the provincial or county level. The power of selecting the expert is with the provincial or county level project office. At the provincial level, they mostly provide the technical support but at the county level, where there is more practical experience, the support is less technical but more practical, such as how to conduct the specific project component. (Respondent N3)
The provincial experts often also played a role in approving the county plans and reports, as the annual plans of the counties were combined into a provincial annual plan, and submitted by the provincial PMO.
We as the provincial experts know the national policy and regulation and the trends from the grass root well. The counties design their proposal based on the eyesight of a county, while our provincial team bases on the provincial viewpoint. It is different. We make the proposals based on the National Health Reform and the need of the work of provincial health service. We regulate the exploration of innovation, to make it more reasonable and meaningful. In this process, our opinions are not always consistent with the views of the counties. When we have different opinions, we will discuss the issue and examine which one is better. 30
(Respondent N8) The contribution of the provincial and county level experts was however perceived as being of varying quality from an (inter)national project management perspective:
As to the provincial level, it was quite uneven among the provinces. Some provinces expert teams have done a very good job and they were evaluated and guided by the provincial project office. So they played a very good role. But in some other provinces they have not got this kind of mechanism….For other provincial expert teams, they were also not very stable. The next level is the county level. I think it is understandable that sometimes they could not play a good role because it is not easy to find a really good expert in the counties. So in some counties there experts were quite good but in some other counties, county experts didn’t play their role. (Respondent N7)
The national experts, mostly academics, were formally contracted on a yearly basis by CPSM and were managed tightly as well. The contracts specified in detail the tasks the workload for each expert in detail. Tasks mentioned by the experts include:
1. Review of Annual Plans by Provinces (and hence by counties) 2. Provide Technical Assistance 3. Research on demand, and for evaluation 4. Synthesis of results, e.g. in guidelines/manuals. 5. (To be informally available for help to counties and provinces.)
As the national experts played an essential role in the formal planning and control activities of CPSM, their contribution was time consuming, required lots of travel, and was tightly monitored for being done properly and on time. As the opportunities for research were scarce, and the operational and concrete nature of the project didn’t necessarily match their expertise, interests and time schedule, not all national experts were equally eager to continue to work on HXI. Around half of them were replaced during the project.
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In fact after the second year they made quite a few changes in terms of the people on that expert panel. One of the problems was that they hired the expert panel to travel to the counties to work with them on an intensive basis. But they didn't do that. They have other jobs and they didn’t want to travel and probably have some difficulties to travel to some of these rural areas (Respondent N4)
For the experts, they are more interested in the research subjects because most experts are from universities or research institutions where they are required to do academic research. So if you ask them to do supervision and take a lot of business travel for that, the motivation would not be very high. (Respondent N6)
Through their written detailed feedbacks, as well as the many supervisions meetings, several national experts established effective working relationships with some of the counties, and were then often also approached directly and informally by phone, email, or in the margin of a supervision meeting. (see the in depth case studies for examples). Thus they may engage with the county health bureau in discussing the design and improvement ex-ante, and not just ex-post via formal review and technical assistance requests.
I participated in many works such as how to develop the clinical pathway and how to control the quality. But from the implementation, a lot of problems emerged, for example that even though the patients had the access to the clinical pathways, sometimes the clinicians said that the patient was not suitable for the pathways. The exclusion rate was very high. To solve this problem, I discussed with the national experts….Then they gradually built up the idea of the ABC classification. (Respondent N9)
3.7
Incentives: Carrot & Stick
The design of HXI recognized that at the time of design, the financial incentives in Chinese rural healthcare formed a barrier for improvement. This holds for example true for the income models for doctors and hospitals, in which medication prescriptions, diagnoses, and treatments such as C sections 32
played an essential role. The national health reform countered these barriers, for instance by initiating essential medicine lists and clinical pathways. HXI embraced the principles of performance based financing and performance based management, and encouraged counties to implement it as part of HXI components 1 and 2. The performance based financing enabled paying provider organisations based on quality using indicators such as patient satisfaction, adherence to pathways, provisioning of preventive services, et cetera. The performance based management within the provider organisations subsequently continued this practice by paying performance based salaries. In some cases more than 30% of the salary became performance based. As the national health reform and Health XI raised available budgets, the performance based mechanisms have mostly let to increases in budgets and salaries, and it was therefore typically viewed as a reward. Occasionally however, it led to penalties and to salary reductions. Similar performance incentives principles were also designed into the project itself. There were performance incentives at various review moments. The total budget allocated for these purposes amounted to 2.9 M USD. At a first review in 2010, there has been a special reward for the first place and for 9 more counties ranked as high performing counties and a warning for the lowest performers. We ranked all the 40 counties as well as the provinces (but later we found that the province ranking had little meaning in this action). We rewarded the first county (Jiulongpo in Chongqing, see Chapter 6) for $200,000 and the next 9 counties for $100,000. For the last 10 counties, we talked to/alerted them in the supervision meeting and told them if in the next year their performance was also not good enough, then an exit mechanism would be applied. (Respondent N3) The performance based subsidies could only be spend on additional project activities, not on salary increases of staff involved. Next to a financial element, the performance payment induced a competition, and recognition of achievement. The recognition of achievements in the first review is reported to have been widely appreciated by the receivers, and to have stimulated others to improve until the second review. This recognition from the central level as well as the World Bank was so important for them to go ahead….. we observed the winners, how happy they were and how determined the slower ones were to catch up to win in the second round…..Money is not so important, but they viewed the reputation more than the money. (Respondent N1) A case writing competition was scheduled for project completion, but this idea was abandoned.
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Another performance related design feature of HXI was the ‘exit mechanism’. According to the exit mechanism, counties which didn’t perform well enough could be excluded from project participation following the mid-term review. Initially five counties were considered for exit, and were given another six months to show improvement. After these six months, two of the five were still considered not to have delivered the agreed improvement. In the end however, the exit mechanism was not applied, to prevent long term consequences for those involved.
3.8
Evaluation
The timing of HXI and the selection of counties have had consequences for the evaluation. As a result of the delayed start of HXI and early announcement of the National Health Reform, the overlap between the two has been considerable, and has in fact been purposively exploited. As a result, it has become infeasible to disentangle HXI and the national heal reform in the evaluations of the innovations.
Another fact I would like to point out. Starting from 2009, China has started the national health care reform and the counties also got a lot of funding for it. For HXI, the counties also conducted the national reform at the same time. So it is difficult to distinguish the effects from HXI and hard for us to define the success of HXI. (Respondent N10)
A collection of health related statistics have been collected via the National Household Survey for both the HXI counties and a set of control counties. These measurements have however not been considered for (design of) controlled evaluation of the HXI innovations. Such controlled evaluation is non-trivial as different counties and provinces have implemented different combinations of innovations and with different degrees of success. Hence, although it would provide insight on the effectiveness of HXI as a project, it would be of limited validity to evaluate specific counties or innovations. Hence, the evaluation has predominantly relied on before-after designs at county or innovation level. Given the interference with the National Health Reform however, the lack of controls, and the small sample size (typically single case studies), these evaluations have yielded weak evidence. This has
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hindered the national experts in writing evidence based reports and guidelines on the basis of the HXI pilots. At the national level, they asked the experts to conduct the supervision but for the experts, it was very difficult to find the evidence for dissemination simply on the basis of the supervision. The experts need strong evidence to disseminate the practices and for the evidence it needs scientific research. But there was no budget to do the research. (Respondent N6)
As illustrated by this quote, the evaluation has been significantly impacted by the focus on dissemination of best practices to the benefit of the National Health Reform.
…if we look back at the design of the project, we find that the project wants to gain data or evidence for the government at different levels to improve the health reform agenda. So the main objective is to gain the good practice on the health reform rather than (to explore) the poor performance counties. Also this was not a scientific controlled study to have the comparable groups to be evaluated. (Respondent 1)
Somewhat paradoxically, the best practice dissemination priority has interfered with the rigor of evaluation. The focus on best practices has also limited the effort to learn from failures. HXI clearly allowed failures, and has provided a setting in which participants have felt safe to fail (as is pre condition for successful innovation).
I’ve been in thousands of meetings during my life. But our meetings in H11 are very much different from those ones……These are meetings for communication. All parties are equal. (Q: do people feel safe?) Yes. As I said in the beginning, the project counties and I are friends and I only give them guidance or support but no orders. I won’t criticize them and I think it makes no sense. I think the meetings are very effective. (Respondent 8.)
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Still, when fail occurred, they received little attention, and the focus was redirected to successes, rather than trying to learn from the failures. Learning from failures is valuable as it allows to create evidence of what went wrong and how future failure can be prevented. HXI had no systems in place to learn from failure.
At the very beginning, the project allows failure. It is not common to terminate the project in the middle and usually if it is a one-year activity, we would terminate it in the next year. For the reasons to terminate this activity, everyone knows it and usually no one will talk about this failure….. (Respondent N6)
The evaluation has also been impacted by the novel design of HXI, where there was much more room for bottom up variation and decision making, creating a greater need for reporting to the HXI management. Especially in the first years, the aforementioned tight project management in the first years appears to have prioritized reporting and accountability as evaluation objectives. This may have interfered with the methodological strengths of the evaluation, and hence the development of a sound evidence base on innovations for rural health reform in China. In this respect, some respondents mention that evaluations activities have been reduced because of scarce budgets. It appears however, that not all funding opportunities for more rigorous evaluation have been fully exploited.
….I think the project started very badly on monitoring evaluation…….. the World Bank provided 10 million dollars for the evaluation of this project for county by county and different innovations. The Chinese rejected the great offer. (Respondent N4)
3.8
Project Leadership
Leadership was one of the final topics in our interview, yet usually popped up much earlier as an important subject. Firstly because many of the central level staff and experts believed leadership to be a crucial determinant of county performance. Good leadership was identified as a necessary condition for successful innovation. 36
A precondition for success is a pro-active and stable leadership team (Respondent N2) Generally speaking in China, if you want to do something well, firstly the leader is very important and the will of the leader is also important and it will decide whether they would do it well or not. (Respondent N6) With regarding to the county level good leadership was often defined in terms of uniting stakeholders, setting the direction, involving staff, competence, and working hard. Health XI involves a lot of corporations with other departments. So whether the leader is good at the cooperations with other departments and whether the leader can win the trust or get the support from other departments is also important for this project. (Respondent N6) Lack of county level leadership was viewed to be fail factor for innovation by respondents. It occurred because because there was no health bureau director for considerable amount of time, or because of successful leaders were promoted and the follow up took time, or leaders just didn’t prioritize Health XI. Provincial level leadership only occasionally surfaced as a driver of success, and in fact it only did in two cases where the provincial level was particularly active. The case studies and their synthesis in Chapters 4-7 provide further insight into county and provincial leadership. Respondents also mentioned the importance of leadership at the World Bank, and the national level. Several respondents praised the leadership contributions of early leaders involved in the preparation and the design phase, for their visionary contributions. At the World Bank and national level, leadership continuity appears to have influenced HXI as well. Both for CPSM and the World Bank team the leadership changed several times during the project execution. These leadership changes mostly occurred in the first project years, which were already challenging because of the difficulties the counties had with designing and implementing innovations, and the dynamics of the rural health reform. The robust design of HXI as well as the consistent efforts of the CPSM and World Bank staff may have provided a counterbalancing force of stability in this crucial period of HXI.
3.9
Sustainability
Respondents were consistently positive about the sustainability of most implemented innovations. In their view these innovations had become accepted routines in the counties. (These views are confirmed by the case study reports in Chapters 4-6 and their synthesis in Chapter 7). As the HXI 37
budgets played very limited roles in financing the operations of the innovative practices, respondents don’t expect that their sustainability will be affected when HXI reaches its end. For this project, the money was not used for the service provision but for seeking the mechanism such as the workshop, meeting, consultant services and operational researches, these kinds of financial support, which are for county and provinces the No.1 difficulty. ….. So the sustainability for the continuation of the best practice will be not the big problem. So this is the difference from this project and the previous projects. (Respondent N1) For example, the medical aid insurance has already been implemented for a while and the people have already got real benefits from it. If they stop it, people will not agree. Also the payment reform will not stop. (Respondent N7) On hindsight, several respondents have indicated that Health XI is not only about introducing new practices, but perhaps most importantly about adopting a new mindset, focussed on continuous quality improvement. Respondents differed in opinion when thinking about the sustainability of the continuous quality improvement and mind set changes. Several respondents at various levels believed indeed that the change of mindset counties have made cannot be easily undone. I am sure that the imprint of this continuous quality management circle will sustain. It is like the sparkle of the pilot. The one important asset of this project is the capacity building management for all the 40 counties. Although we cannot quantify it, surely there will be improvement. It is an intangible benefit or achievement of the project. (Respondent 2) …after they have formed this kind of thinking, it is difficult for them to go back to the previous working style. (Respondent 6) Other respondents were less optimistic and pointed out that if annual innovation plans are no longer officially required, reviewed and monitored, counties and provinces might abandon these working methods, especially so as official new commitments will demand their future attention.
3.10 Dissemination Dissemination was another topic that was emphasized by the respondents. Many involved were eager to point to dissemination activities at national health reform events, to the many international visits by World Bank invitees, other Asian counties, television documentaries, et cetera. It is clear that long 38
before HXI ended, systematic and frequent dissemination activities among HXI counties, to non-HXI counties in the same provinces, to other provinces in rural China, and in fact across the border had taken place. As to the dissemination within the province, during the second year, we have started to conduct this kind of work. There are two kinds of dissemination activities. First , in each province, there were 4-6 project counties and we have got the annual meetings and in each meeting the project counties would attend and would communicate with each other. They would submit some reports of their implementation as well as some project progress reports. Secondly, within the province, they also would conduct some dissemination to the non-project counties. In some provinces, they have done a very good job in this, such as Henan, Jiangsu and Chongqing. (Respondent N6) Meixian and Jiulongpo also received many visits by other counties, by even non HXI counties or provinces, and even non Chinese, as the five countries from the Mekong river delta, also the World Bank management team from different region. Also more than 18 senior officials visited Yi Yang. (Respondent N1) For the county hospital reform, the NHFPC announced a notice several weeks ago that more than 26 training courses would be held for more than 2000 counties, to show them the best practice at the county level. Experts will give presentations on the skills or the theories of the county hospital reform. There are only 2 county level presentations among these 2000+ participants. The (Henan HXI counties, ed.) Yi Yang county and Wu Zhi county were the two representatives of county best practice to show the experiences among these 26 training courses all over China. (Respondent N1) Within HXI, there was much sharing of best practices, as for instance illustrated by the batch wise approach to developing innovation plans during the early HXI months described above. (the organized competition didn’t appear to have negatively influenced sharing of successes.) As also witnessed by the case studies in Chapters 4-6, there is evidence that such dissemination has led to implementation of the innovations developed in one HXI county in other HXI counties. Moreover, the case studies reveal evidence that some best practices are being spread under provincial guidance. Our qualitative analysis has however provided little evidence that the case study best practices were being adopted county-to-county by non-HXI counties.
As was the case for sustainability, respondents differ in opinion regarding the dissemination of the double loop learning, the general capacity for continuous quality improvement. Most respondents viewed the continuous quality improvement practice to be hard to disseminate, expecting that the 39
dissemination would only regard the innovations, not the continuous improvement. Some respondents however, argued that you cannot separate the continuous improvement from the innovation. For any intervention, the dissemination is the combination of the continuous improvement system and the specific method. Take performance management for instance, They not only share the indicator system they develop but they will also explain to them the theory behind this, the evidence based, rational deployment of the whole process. So any dissemination activity should be the combination of the two. (Respondent N2)
3.11 Conclusions HXI has gone through an extensive design process, as was required to harmonize the priorities of the various stakeholders involved, while staying aligned with the National Health Reform. As the start of HXI was delayed, it started later only half a year before the National Health Reform which was announced earlier than initially anticipated. Not only did the National Health Reform therefore influence the content of HXI, the changes in timing also brought changes in the relative positioning. The role of HXI shifted from experimentation of innovations to aid the design of the reform, towards piloting of innovations for best practice implementation. These developments brought changes and complexities, and even some confusion in the preparation and early project phases. Overall however, there is wide consensus among the respondents that the design of HXI was well aligned with the National Health Reform. This in turn has motivated provinces and counties to participate actively in Health XI and helped them to be effective. The implementation of innovations in HXI may well have benefitted from the relative proximity of the starting dates of HXI and the National Health Reform and the way the design of HXI leveraged the resulting parallel execution.
The alignment with the reform has also facilitated the sustainability of the innovations, as they were not experiments, but formed the implementation of the reform for HXI counties. Often, sustainability became self-evident. Moreover, the alignment catalyzed dissemination activities within Health XI, within Health XI provinces to non-HXI counties, and to other non-HXI provinces.
Respondents suggested improvements for the design regarding the selection of counties, and the evaluation. Although, criteria for county selection had been carefully formulated, several respondents 40
would rather have included a better motivated set of participating counties, which lived up better to commitments made, e.g. regarding leadership and human resource availability. While, HXI supposedly could have achieved more with a ‘better’ selection of counties, the eventual variety in project counties can also be valued as being richer. The variety enables better insight in how differences in contexts and interventions produce outcomes. This richness has however been disregarded. The evaluation activities have been focused on accountability reporting and on documenting show cases, best practices to inform the reform. However without controlled evaluation designs, without understanding variation, one cannot reach conclusions about determinants of successful counties. In addition, this approach inhibits learning from failures, which is equally valuable for understanding sustainable innovation, and scaling up. Rural China consists of 2,700 counties, not all of which provide favorable contexts which meet best practice selection criteria. The majority of the rural population doesn’t live in best practice counties, but in average, or even worst practices. Evidence on how to advance the reform in these counties, which may well form contexts than are essentially different from best practice counties, is called for as scaling up to sustainable innovations in these counties is of great value.
The leaders at the various stakeholders have been in an important force, especially in the early HXI years, when HXI was seeking direction and momentum. In subsequent years, there have been repeated changes at HXI leadership positions among the stakeholders involved. Given the importance respondents attach to leadership for the innovative project HXI, with complex top down and bottom up processes, such changes were not without risks, as also witnessed by the varying impacts (absence of) leadership has had in project provinces and counties. The solid design and consistent execution of the project formed a basis upon which the various leaders have advanced the project to the appreciation of the shareholders. HXI has been tightly managed. The degrees of freedom brought about by bottom up innovation were counterbalanced by tight control structures, where HXI management ensured to be informed in detail about the county innovation plans and the progress made. In combination with the leadership and support, this resulted for the national HXI management to have been an important driver of innovation and progress. While this may have functioned effectively in HXI, this raises questions about scaling up. As pointed out repeatedly by respondents, HXI is not about the formal technical designs of innovations, but about ‘management’ skills, bringing about a change in ‘mindset’. The tight project management which enabled these, is not straightforwardly scaled up to larger collections of rural counties to further advance the rural health reform. An effort in which provincial health bureaus are 41
trained to take up this role, under national guidance, may yield potential to follow through on HXI on a larger scale. We refer the reader to Chapter 8 for a further discussion of future activities and recommendations. The experts have played a decisive role in the project. The contributions of the international experts have been most well received in the initial stages, when HXI ‘innovators’ (Rogers, 2003) where reaching out for international best practices. National, provincial and county level experts have been of importance in subsequent stages, when counties struggled with the ‘practical’ county specific design, implementation and adaptation issues. The degree of expert involvement varied considerable among provinces and counties. In some (best practice) cases national experts were operationally involved in design and adaptations of the innovations, and made valuable contributions. Other counties appear to have been unable to organize for effective expert contributions. The formal role of the experts has been included in the tight top down management, and has not always been experienced as productive. This holds particularly true for experts with an academic orientation. The results indicate that a sufficiently large and committed expert base is valuable to advance rural health reform.
Motivation has been an important phenomenon in various stages and at various levels of HXI, albeit sometimes unspoken. In a formal sense, motivation took the shape of incentives and reporting, both of which are forms of extrinsic motivation. HXI asked counties to implement innovations which changed financial incentive system, as also implied by the National Health Reform. The management of HXI itself also used financial incentives, for instance at mid-term, and HXI relied extensively on reporting and performance benchmarking. HXI project management ‘walked the talk’. The external motivators have also been extensively implemented in the innovations in the HXI counties, with pay for performance by NCMS offices, performance based payment of public health, performance-based departmental budgets and salaries. Moreover, innovations benchmarked performance at organisational, departmental and personal levels, and sometimes went a long way in making the performance benchmark scores public. The effectiveness of these performance incentives is often illustrated through examples of best performers. There is less attention for the effects financial incentives and public reporting has had on worse performers. For instance, if the incentives are effective, why is there still underperformance? This topic appears to be related to cultural characteristics related to addressing underperformance and failure. The resulting management dilemmas surfaced explicitly when HXI considered applying the ‘exit’ procedure. When a small number of counties repeatedly failed to achieve the performance 42
requirements the formal consequence for them was to exit HXI. It was however decided to continue their participation. Constructively addressing performance problems, creating an environment where it is safe to fail, and being able to learn from failure, are management capabilities which are important for innovation. For cultural reasons, it seems, that HXI has focused much on best practises and therefore has missed other opportunities for learning and development. Interestingly, many respondents spoke about changes in mindset, attitudes, new ways of thinking, and other changes which refer to intrinsic motivations, as opposed to the aforementioned extrinsic motivation. Intrinsic motivation also occurs in the many references respondents made to leadership, mentioning the importance of guidance, inspiration, and empathy. Following scientific understanding of innovation of in Western counties, and based on our findings, we conjecture that intrinsic motivation may have importantly influenced the outcomes of HXI. Most importantly, it may explain differences in the performances of provinces and counties. Intrinsic motivation deserves further exploration and deserves to be more explicitly addressed in the design of follow up projects.
Before more extensively addressing future innovation activities and research in Chapter, we now invite the reader to the three case studies presented in Chapters 4, 5, and 6, and the case study synthesis in Chapter 7, which also incorporates the findings of this present Chapter 3.
43
4. Performance Based Management in Mei Xian, Shaanxi 4.1
Mei Xian
In this case study, we focus on the implementation and results of one of the innovations implemented by Mei County: Performance-Based Management. Mei county, or Mei Xian, is one of the 107 counties in the province of Shaanxi, five of which participated in HXI. Shaanxi is a less developed province with a 2009 per capita net income of 4,105 RMB for farmers. Mei Xian covers 863 km2, and has a population of 310,000. While it is mostly flat, it has some more mountainous areas, where traveling is more difficult for patients and health workers. To execute the overall project, Mei Xian has received 8,500,000 RMB from the WB loan over the years 2009-2013 (18% of the total HXI budget for Shaanxi). The budget has been spent on equipment (39%), health service (20%), training (13%), technical assistance and applied research (10%) and project activities (18%). When HXI started, Mei Xian had already earned the distinction of being ‘national health city’ for its achievements in (public) health services. Prior to HXI, Mei Xian participated in HVIII.
4.2.
Performance Based Management
The national health reform has prioritized the relation between performance and reimbursement (Wagstaff et al. 2009). Resonating this aforementioned national health reform priority, HXI explicitly identified Performance Based Management (PBM) as an innovation which can achieve alignment between performance and reimbursement. Notice that this alignment connects the insurance and procurement practices of the NCMS offices, with the health service delivery of the provider organisations, whether in treatment of disease or in preventive (public) health services. Hence PBM may comprehensively connect the first three components of HXI at county level.
In their baseline assessment, Mei Xian identified the following performance problems, in view of the national health reform and HXI priorities: 1. Lack of effective incentive mechanisms for quality, 2. Clinics focus mainly on net income, 3. Lack of public health initiatives. 44
More specifically, the Mei Xian health bureau staff indicates that effective incentive mechanisms were lacking prior to 2009. The working style of most employees was affected by the perception that working hard was not rewarded. This situation was perceived to negatively impact the employee attitudes, especially the professional workforce. In 2006, the number of out-patient visits decreased by 22%, and the number of inpatient visits decreased by 23%. Moreover, the contributions to public health resulting from the (public) health service delivery remained unclear. As salary allocation was partly based on revenue, over prescription of medicine, in particular antibiotics and unnecessary diagnostic services were not uncommon. In 2008, 33% of the outpatient prescriptions received two or more antibiotics, 12% of the prescriptions contained hormone treatment, and 55% percent received intravascular infusion. The average in-patient cost increased 11% and average out-patient visit cost increased 28% compared to 2006.
The purpose of implementing PBM was to address the performance problems identified in the baseline assessment by creating transparency on delivery and subsequently rewarding appropriate delivery, both at clinic level and through salaries. This case study regards the implementation of PBM by the Mei Xian government from 2009 onwards within the framework of HXI. Earlier plans by Mei Xian’s health bureau to introduce PBM date back as far as 2006.
Before going into the objectives in more detail, we remind the reader that within the HXI framework, 50% of the overall available budget was used for construction of local health clinics, while the other 50% was available for comprehensive improvement of the health system (insurance, delivery, and public health). The health bureau of Mei county identified the following objectives for the performance based evaluation, as developed within the HXI framework:
1. to accelerate the improvement by evaluation; 2. to accelerate the construction by evaluation; 3. to accelerate the management by evaluation; 4. to combine the evaluation and construction; 5. to focus on the construction, by performance evaluation and the policy of government supplementary payment based on the performance.
45
An interesting feature of the PBM system developed by Mei Xian is that it comprehensively includes township health clinics (THCs) and village health clinics (VCs). We remind the reader that in rural China, the VCs function as primary care centers. The township clinics THCs form the next higher level, which is in turn followed by the level of county hospital(s). The county health bureau holds responsibility for this infrastructure.
Total
Zhen’an
Hanbin
Ningqiang
Mei
Xunyi
County Year 2008
173
232
163
57
200
189
18
17
7
40
19
Medical cost 180
391
90
125
132
302
Other fees 23
32
15
24
16
38
Medical costs 18 Other fees Year 2013
Table 4.1 Expenses per time for outpatient treatment (Source: Report Project Office Shaanxi)
The results described in the ‘Evaluation Report of Final Phase of Rural Health Development Project in Shaanxi Province (Project Office of Shaanxi Health and Family Planning Commission, July 2014) show the achievements of Mei Xian in different areas. Via Tables 4.1-4.4 we highlight some of the achievements made over the HXI period.
Comparing the years 2008 and 2013, the expenses for outpatient treatment have decreased in Mei County with 38%, despite inflation, salary increases, and indeed rising average outpatient treatment costs at the provincial level. The average hospitalization expenses have grown with 30.2% in Mei County, however, this is lowest among Shaanxi HXI counties. The self-payment ratio for hospitalization has decreased from 78.9%, highest among the Shaanxi HXI counties is 2008, to second lowest at 50.3% in 2013. While in 2008 the number of outpatients which was satisfied about the health services was already highest among the Shaanxi HXI counties in 2008 at 70.8%, Mei Xian remained to have a considerably higher outpatient satisfaction score of 92.4 being satisfied (and 0 unsatisfied.) As Table 5.4 shows, 46
patients indicate to have seen a great improvement in convenience of seeing a doctor over the HXI period.
Year 2008 Average hospitalization expense per time (yuan) Average other expenses per time (yuan) Other self-paid costs per time (yuan) Self-paid ratio (%) Year 2013 Average hospitalization expense per time (yuan) Average other expenses per time (yuan) Other self-paid costs per time (yuan) Self-payment ratio (%) Growth rate of average hospitalization expense per time (%) Annual growth rate of average hospitalization expense per time (%)
Total
Zhen’an
Hanbin
Ningqiang
Mei County
Xunyi
3308
3604
2388
5019
3555
2724
453
435
199
807
503
448
2476
2617
1778
3574
2806
2063
74.8
72.6
74.5
71.2
78.9
75.7
5907
7833
5917
6551
4628
5366
723
954
530
1056
511
720
3040
4064
2871
3366
2329
3032
51.5 78.6
51.9 117.3
48.5 147.9
51.4 30.5
50.3 30.2
56.5 97.0
15.7
23.5
29.6
6.1
6.0
19.4
Table 4.2 Hospitalization expenses, self-payment rate and growth rate (Source: Repot Project Office Shaanxi)
Year 2008 Year 2013
Total
Zhen’an
Hanbin
Ningqiang
55.8
52.9
65.0
40.4
Mei County 70.8
Xunyi 52.0
Satisfaction 83.7 87.7 81.2 80.4 92.4 75.7 General 15.8 11.2 18.2 18.8 7.6 24.3 Dissatisfaction 0.5 1.1 0.7 0.9 0 0 Table 4.3 Overall patient satisfaction on outpatient service (Source: Report Project Office Shaanxi)
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Table 4.4 Patient views on convenience of seeing a doctor in 2013, compared to 2008 (Project Office Shaanxi)
4.3.
Two Tier Evaluation Design
The PBM system developed by Mei Xian is often referred to as “performance based evaluation”, thus emphasizing the data-driven, transparent, characteristic of the approach. The system has two tiers. The first tier regards the THC and addresses the performance based evaluation of the THC by the county health bureau. The second tier regards the evaluation of VCs as well as the evaluation of the professionals in the THCs and the VCs, both by the THC management. The THCs thus function as cores of the two tiered evaluation system: from their perspective, the system has an external evaluation and an internal evaluation.
The external evaluation is relevant for the performance based budget allocated to each of the THCs. The external evaluation of Mei Xian’s 11 THCs by the county health bureau is conducted by a panel.
The internal evaluation subsequently refers on the one hand to the performance based staff salaries (in THCs and VCs), and on the other hand to the supplementary and basic health care funds available to each of the VCs. Each of the THCs organizes its evaluation team for individual staff evaluation. For example, the Maija THC evaluates 9 VCs as well as the staff of the Maija THC and the staff of the 9 VCs. Figure 4.1 is taken from the dissemination materials of the Mei County Health Bureau and illustrates the system.
48
Figure 4.1 The methodology of performance evaluation in Mei Xian (source: Mei Xian Health Bureau)
The initial innovations which started in 2006 focussed on quality evaluation. The innovations which were started under HXI in 2009 included performance-based elements. More specifically, Mei Xian designed an indicator set (see also Figure 4.2) to measure performance and based 30% of the reimbursement on the scores on the indicators in the set (while 70% remained fixed). The indicator set was adjusted for THCs and VCs in mountainous areas. Detailed examples of evaluation forms containing 2014 indicator sets are provided in Appendix 1. Table A.1 refers to clinic performance. Tables A.2-1 to A.2-6 provide detailed indicator sets for various types of professionals and management positions. 49
Performance measurements take place each month and the VCs and THCs report on a monthly basis to the county health bureau. Twice per year, the county health bureau reports a summary to the provincial health bureau.
Figure 4.2. Management control structure for PB (Source: Mei Xian health bureau)
The concept of PBM including validated definitions of quality indicators and a system to capture data in a reliable and systematic way was new to all provincial and county level officials and staff involved. In fact, many were even unfamiliar with the concept of “performance” for health service delivery: “We knew that in companies and factories they have this kind of thing, but we had no idea what it was exactly. We are in a process of learning while doing it.” (Respondent M1) Prior to HXI the facilities fully relied on fixed government budgets. One of the respondents stated that in this situation clinic staff “did not work hard for no economic incentive existed”.
4.4.
Alignment between the National Health Reform & HXI 50
The implementation of PBM in Mei Xian has been fully embedded in the implementation of the national health reform. In fact, Mei Xian perceives that PBM has served as an important means to implement the health reform announced in April 2009. Implementing PBM therefore served to attain both HXI as national health reform objectives. Various respondents stressed that the urgency which with PBM was implemented was greatly affected by both HXI and the national health reform: “Almost at the same time of the issue of the Evaluation Guideline for Rural Health Service Quality, the reforms of the health care system of China began to encourage counties to make efforts on performance based management, and this guideline provided great reference value for the counties. (Respondent M2)
HXI demands counties to implement comprehensive reform through the use of a selection of simultaneously or subsequently implemented innovations. Mei County implemented PBM as well as various other innovations, whose effects have interacted with the effect of introducing PBM. The actual evaluation of the impact of ‘PBM’ in isolation, if at all meaningful, is therefore problematic and will not be considered further in this qualitative analysis.
4.5
Top Down Supervision & Management Control
In the Shaanxi Province, the selection of counties for inclusion in HXI has clearly been top down. The counties were chosen by the provincial authorities, the intrinsic motivation and perceptions regarding the HXI interventions at county played a modest role: “The reason why the directors initially did not believe in performance based management is that they thought it was impossible to abandon the budget framework. However, in China, we handle affairs in a rather compulsive way. We were ‘asked’ to do it. Our leader said that if you do not participate in the reform, we will reform you.” (Respondent M1)
The main responsibility and leadership has been with the county health bureau, as it works directly with the health provider organisations while the provincial authorities control at a distance and have a bridging role with the national level. “The province mainly plays the role of supervising. It also examines the plans and visits the counties to verify the execution. The province does not have any 51
compelling influence on the selection of THCs and VCs. The decision is upon the county itself. The province only supervises them.” (Respondent M2) Moreover, the Shaanxi provincial health bureau perceives to have adopted a novel governance approach as a result of PBM, allowing Mei Xian more control over the actual implementation. “In the past, the management was from top to bottom. The management was very extensive and broad. Thanks to the performance practice, the management becomes easier for different levels. The indicators of the township centre are well defined and weighted.” (Respondent M2) As a result, the Mei Xian health bureau and Mei Xian government play an important contextual role. While they report to the provincial health bureau twice per year, the actual flexibility and freedom is perceived as substantial. Moreover, the contacts between the different stakeholders on county level intensified, thus enhancing mutual understanding and interdependence at the county level. In China, if you want to implement a policy, a reform, you must have someone (…) who has logic thinking and someone as the leader who is strong enough. (…) Of course, if there was no such supportive boss, we would not have performance management. (Q: Is the leader at the provincial level or at the county level?) At the county level. (Respondent M3)
The THCs are ranked every year and the official report is sent to the participating institutions so all THCs are aware of the details of (changes in) evaluation indicators. Each THC will subsequently have a meeting with the Mei Xian health bureau to discuss the evaluation reports. However, the health bureau does not make absolute decisions regarding the performance based reimbursement, as the total available budget for reimbursement also depends on contextual policy decisions. For example, there may be policy decisions regarding the retirement benefits of employees, which affect the available budget. Likewise, other reforms and government policies (e.g. fixed salary payment by government) may impact budgets and salaries. Some of the respondents perceived the main decisions related to salaries to have been made beyond the authority of the Mei Xian health bureau authority, and therefore in fact beyond the sphere of influence of HXI: “Since it is a financial issue, not even the health bureau can make a decision on this.” (Respondent M4) 52
Despite these limitations, respondents perceive that the performance based salaries resonate with the management priorities in the service delivery processes and at least partially replaced previous management controls: “In the past, the payment is basically based on the capitation. For now, it is more about the performance. The working staff feels greater pressure on their shoulders than before. The ‘guanxi’ is not as important as before.” (Respondent M2) As part of the PBM implementation, an extensive management control structure at county level was put in place to manage the two tiered system. Figure 4.2 provides a graphical representation of this structure. This extensive structure appears to have replaced operational supervision by the Shaanxi provincial health bureau, and loosened the operational top down supervision. The resulting added space for bottom up steering is covered in the next subsection. The citation below accurately describes the interaction between top down and bottom up mechanisms as revealed through the qualitative research: “In China, if you want to get something new to be done, you start with the topdown measure, otherwise, no one would do it. You can say that if something is to be implemented, you have to use this top-down method. The performance based management is listed, so you have to get it done, or you will lose your position. After the policy is in place, you also need the bottom-up approach to experiment and to pilot, so you can have more detailed operational guidelines and indicators”. (Respondent)
53
4.7
Expert Design and Bottom-Up Adaptation
The implementation of PBM in Mei Xian started in 2009 with significant involvement of Xi’an Jiao Tong University. Both the Mei Xian health bureau experts as well the provincial academics involved received training by national and international experts. The various training activities addressed a variety of topics such as health care delivery, accounting, finance, development and reform. While the national and international experts continued to be involved and appreciated as a critical success factor during subsequent stages of the project, respondents indicated that their involvement was particularly intense and valuable in the initial design stage. Moreover, respondents explicitly valued the support by the provincial academic experts who greatly contributed to the concrete development of the initial set of 160 indicators: “Mei county felt not capable enough, and delegated the work to Prof. Gao in Xi’an Jiao Tong University and his students” (Respondent M2) The influence of international experts is illustrated by the inclusion of patient satisfaction (see also Table 4.3) as a performance measure, which was a novelty for the Mei Xian health bureau. World Bank experts introduced it as a performance measure and illustrated its importance by referring to a project in Brasil where patient satisfaction even was the sole indicator. Eventually, this evidence convinced Mei Xian to include measures on patient satisfaction in the initial indicator set.
The initial comprehensive indicator set included 160 performance indicators, with a total weight of 1000 points. This initial set, co-designed with provincial academic experts, has been perceived as complex: ‘only the professor and his assistants understood the system’. Since 2009, the indicator set and the indicator weights have been evaluated yearly among the stakeholders on THC and county level. Mei Xian made yearly adjustments, assisted by continued training and expert support ‘on the ground’. The County Health Bureau kept a list of contact data of national experts on the wall of their office. Various respondents describe the adaptations as a transition from ‘complex’ to ‘simple’ or refer to a ‘Keep it simple’ approach. Adaptations have been especially significant during the early years 20102012 when the service performance was changing for the better. For example, the weights of the immunization indicators were reduced as immunization became a common practice. From 2013 onwards, the adjustments were minor. The 2014 indicator set consists of a much reduced number of only 44 indicators with a total weight of 300 points (see Figure 5.3). 54
Adaptation of the PBM system has primarily been a bottom up process, involving professionals from the clinics. Nevertheless, developments incited by the national health reform and HXI priorities continued to influence the performance indicator set. For instance, the comprehensive approach required by HXI and therefore the inclusion of HXI component 3, which regarded public health services, led to increased public health service delivery. This change in service delivery, which matched the priorities of the national health reform, was initially not accounted for in the PBM indicator set. Gaumer (2011) already pointed out in an external expert review that a misalignment existed between the PBM indicator set for the external evaluation of the THCs, and the indicator set for the HXI evaluation at county level. The two tier PBM system subsequently forwarded this misalignment to THC and VC budget allocation and performance based salaries, thus creating a misalignment between HXI and national reform priorities and performance based incentives.
Figure 4.3 Breakdown of performance indicator areas (total score 300)
This misalignment also caught the attention of the Mei Xian health bureau and experts involved when the new emphasis on public health services raised complaints by professionals at grass roots level. The PBM indicator set was adjusted through the addition of public health indicators by 2012. In 2014, the category of public health services has the largest weight among all categories (see Figure 4.3.). “For example, the professionals complained that the workload is too heavy, so the management increased their performance pay. The management elevated 55
the score for workload. In the past, if a physician works also in public health, that part was not paid. Now the workload is included in the performance pay.” (Respondent M5)
The six main items which have played a key role during the implementation and adaptation process and continued to be discussed between local staff, academics, and national and international experts and supervisors are summarized as follows by Mei Xian health bureau:
1. long-term development of performance-based management 2. innovate work style 3. perfecting indicator framework 4. improve feedback mechanism 5. improve (dis)incentives mechanism 6. realize independent accounting
4.8
Financial and non-financial incentives: carrot and stick
While the PBM system is often referred to as an evaluation system by local authorities, it is intended and believed to positively impact health service provisioning through the corresponding financial incentives in the form of budget allocations for clinics and salaries for employees. Looking back on their experiences with HXI, respondents indicate that before HXI started, employees typically focused on income rather than on service, on medical care rather than on prevention, and on bonuses rather than on quality. In other words, the financial incentives of the health system as it existed until 2009 had an effect, which however was counter to achieving the performance improvements prioritized by HXI and the national health reform. The majority of professionals and management wasn’t perceived to compensate these effects by intrinsic motivation, and in fact the system was perceived to have reduced such intentions by professionals. In 2009, the number of outpatient and inpatients had both dropped with more than 20% compared to 2005.
The county level performance is reported to the Shaanxi provincial health bureau. Respondents indicate that these reports are shared and discussed during various meetings, and that counties are 56
aware of their relative performance in the provincial benchmark (where Mei Xian has been mentioned to be a consistent top performer). Provincial health bureau respondents mention using these benchmark figures to stimulate further improvement has not been confirmed by county level respondents however.
Hence financials incentives appear to have been the predominant incentive mechanism. The sensitivity of clinics, management and professionals to financial incentives, is also explicitly recognized in the national HXI evaluation by Fudan University, which qualifies payment reforms to be of key importance to the achievements of HXI: (Fudan 2014:61). As already mentioned, the formal financial controls of the performance-based management have been mentioned by respondents to replace former informal controls such as the ‘guanxi’ (关系). At the same time, it has been mentioned that such change cannot be disruptive in rural China and takes time.
Within Mei Xian, the performance based part of funding and salary accounts for 30% of the total for permanent staff. For the higher paid pofessionals, this may translate into as much as 1000 RMB per month (while the poverty line is roughly at 200 RMB per month in 2013). However only about 50% of the staff working in the THCs is under permanent contract, while the other half is temporary or fixedterm staff (one of which was already working at the clinic for 9 years). The salary of temporary or fixed-term staff is not performance based. Several respondents indeed perceive better performance by the permanent staff to be related to higher payments. On the other hand, the seemingly substantial 30% was not perceived as equally effective by all respondents. Interviewed nurses and a physician were not able to indicate the details of the performance-based system and how it actually affected their own income. “Basically, the [performance-based] pay is related to the quantity of your work. I am not sure of the indicators and the calculation.” (Respondent M6)
As can be concluded from Tables A.2-1 to A.2-6 volume forms an important driver of the performance based salary. Various stakeholders indicate that in practice, the 30% fraction might be too small when intending to change behaviour significantly. “I think my income is mainly dependent on policy change, not the performance based management” (Respondent M4) 57
This perception confirms the general mentioning of respondents that their income has been increasing over the last years. Even after explicit questions, respondents knew no occurrences of employees whose income had decreased due to poor performance. It appears that, at least in practice, the relationship between poor performance and salary reduction hasn’t been clearly demonstrated.
While on the one hand some respondents downplay the effectiveness of the salary incentives, others have been especially sensitive. As with every system of financial controls, the PBM system carries the risk of perverse incentives and soliciting unintended performances. Respondents mentioned some cases of fraud with indicators that have been investigated in the past. In one case, patient visits had been reported that in reality never had taken place. The health care professional has been imposed a fine. “About the dark side, there is payment for the visits to the patients. Sometime they did not visit, but they claim that they did. Actually, we require them to visit a chronic patient 4 times. Another example is the health education, we have specific requirement for them to conducting health education activities, and we even have special funding for them to do this, but they only made little efforts such as making a simple poster or something.” (Respondent M1)
4.9
Leadership
In contrast to some of the aforementioned topics, respondents found it easy to address the importance of leadership and the leadership qualities required for the success of the PBM innovation. This suggests that leadership issues have received much attention in the implementation of the PBM system. As discussed in depth in Chapter 8, respondents related the leadership mostly to the county level. It is worthwhile noting that next to traditional leadership characteristics regarding power and strategic orientation, respondents explicitly valued expertise and empathy.
(What is your definition of a good leader?) Capable and actually love the people. (Respondent)
Leadership characteristics most frequently cited can be summarized as:
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Capable, expert Strong, hierarchical Long term focus Loving, engaging
The content capabilities and expertise of the leaders had been built through long term involvement in several previous projects, and recognized in the composition of the leadership team. The Provincial Health Bureau sent me to manage the projects then, but my labour relation was not moved. After the job transfer, I managed several projects, for example, a Belgium corporation project with Shaanxi, and the World Bank loan projects HVIII and HX. Now I am involved in HXI. (Q: How long have you been working in the Provincial Bureau of Health?) In the earlier times, I worked 2 days in TB control and 2 days in the Provincial Health Bureau. If you do not count these days, my working experience is 12 years (in the Provincial Health Bureau). If you combine the years in TB Control, it would be 16 years. (Q: In the same county?) Yes, in Mei county. I have been working in health related departments for 33 year. I work on component II in this project. (Respondent M2)
4.10 Sustainability and dissemination: business as usual Project HXI, which started in late 2008 acted as the prime force to implement PBM as a means to remedy the shortcomings identified in the base line analysis. As already mentioned, the change set in motion by HXI was clearly reinforced by the national health reform, whose priorities were announced in April 2009, while Mei Xian was in the process of designing the PBM intervention. The national health reforms priorities were long term, and may have helped to view the PBM implementation as a long term activity rather than as a project which was to end with HXI in 2013. The implementation of PBM in Mei Xian County started out with an ambitious design, involving THCs, VCs, all staff involved, provincial, national and international experts, and resulted in a comprehensive 160 indicator performance based evaluation system. Moreover, the financial commitment had been made not only by the Mei Xian health bureau but also by other relevant county level stakeholder organisations. From a national level, the PBM implementation can be considered as a pilot, in Mei Xian it was launched as 59
a comprehensive long term change, supported by all relevant stakeholders. Initial difficulties and anomalies were solved in mutual agreement by adaptations to the initial design. None of the respondent mentioned stopping the PBM implementation or reversing the changes made. Instead the PBM system became accepted as the new reality, ensuring the sustainability of the ambitious and profound county level reform.
The patients in the focus group confirmed that the changes made since 2009 had developed into a new business-as-usual mode and explicitly mentioned to have observed lasting improvements in professional knowledge of the hospital staff at THC and VC level. The patients also indicated that staff attitude had changed to become more caring. When asked to indicate their satisfaction, they indicate about 90-95 on a scale from 0 to 100.
By the end of HXI it appears that the PBM implementation has sustainably changed the service delivery, as well as the incentive system for staff via salaries, and for clinics via performance based budget allocation. As the decisions on the incentive systems are made by Mei Xian health bureau, the PBM innovation has also changed the governance mode of the provincial health bureau. As mentioned above, the provincial health bureau became to supervise at a greater distance, and Mei Xian health bureau gained greater control over its own resources. The emphasis of HXI to work at county level is therefore clearly visible in the sustainable change achieved in Mei Xian. The provincial health bureau has co-initiated these governance innovations and continues to support and promote them as a health system improvement.
Based on their experiences, Mei Xian has developed a “Guideline on the Evaluation of Performance Based Evaluation” that has been disseminated to other counties. In fact, all five HXI counties in the province of Shaanxi have implemented PBM on the basis of the guideline developed in Mei Xian. The guideline has also been shared with HXI in other provinces, with which there is much communication and mutual exchange of practices, via the supervision missions, workshops and further informal communication. HXI counties came to interact frequently and sometimes closely, and the recognition of best practise through the HXI supervision offices of CPSM and Worldbank is highly appreciated and appears to act as performance based reward in itself as witnessed by the citation below in which lacks the traditional Chinese modesty:
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“We can communicate with each other. However, Mei county is the best in term of the project.” (Respondent M1) We have found no direct evidence of implementation of the guideline by non HXI counties in Shaanxi, or by counties beyond the provincial borders. Still, Mei Xian has received much attention from other counties, provinces, national initiatives, as well as internationally. In particular, Mei Xian organized a nation-wide seminar to share their results in 2012. “Mr. H. the director of the project, had been invited to give lectures to other counties for several times. It is also a practice of bottom-up. They asked Mr. H. to give lectures themselves, so it is not an official requirement from the provincial level. The counties asked for the telephone number of Mr. H. themselves. A lot of visitors came from all over China to learn from the experience. Approximately 300 groups have visited Shaanxi.” (Respondent M2)
The results were also shared in the 19th issue of the internal Medical Reform Journal.
4.11 Conclusion One of the innovations Mei Xian has implemented as part of their HXI activities is the comprehensive health system innovation of Performance Based Management. The implementation has subsequently been adapted and improved, and has led to sustainable changes in health service delivery, financial management and governance. Moreover, Mei Xian is considered as a best practice, and the innovations have been reported to be adopted by all HXI counties in Shaanxi, and have been disseminated to a wide national and international audience through guidelines, publications, visits and other events. We may conclude that the PBM innovation has gone full circle in Mei Xian. From being an alien international method, it has become a thoroughly embedded, Mei Xian owned, sustainable practice, which has been successfully disseminated to become implemented in neighbouring counties, and inspiring other counties and countries. The implementation was tightly supervised by the HXI project office, and experienced severe top down commitment. The actual innovation process however was by and large a bottom up process, in which Mei Xian health bureau involved THC and VC management and professionals as well as other relevant stakeholder organisations. The design and subsequent adaptation of the PBM system, in particular the indicator set and weights were therefore a joint effort, which was greatly supported with the help of 61
provincial, national and international experts. The role of experts has been particularly valuable in the initial design stage. Subsequent adaptation can best be characterized as a simplification process. This process was further guided by the national health reform and corresponding priorities by HXI project management. The county health bureau of Mei Xian has formed the nexus of the PBM implementation, as envisioned in the design of HXI which explicitly recognizes differences among counties and encourages county specific innovations derived from the county level base line assessment. The Mei Xian health bureau leadership is recognized as an important success factor. The PBM mechanisms have subsequently enabled enforcement of the autonomy of Mei Xian over the county health system, as the province remained supportive of the innovation and corresponding governance mode. In combination with the alignment of the performance measures with the national health reform, the PBM innovations were commonly accepted as business as usual by 2013 and there is a little doubt about its sustainability. The two-tier system ensures alignment between the health bureau, THCs and VCs and comprehensively regards health service delivery and public health services. A possible direction for extension is the integration of service processes with the county level hospitals, which have so far not been included in the PBM system. Although the indicator set adopted the international practice of including patient satisfaction and related service attitudes, it contains few patient reported outcomes or clinical and health outcomes. Patients have not been involved in the design or adaptation, yet acknowledge improvements in satisfaction and attitudes. A further discussion of the results follows in Chapter 7.
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5. 5.1
Comprehensive Hospital Reform in Xi Xian, Henan
Xi Xian
This case study report focusses on one of the innovations Xi Xian has implemented as part of their HXI activities: Comprehensive Hospital Reform. Xi Xian, or Xi County, lies in the province of Henan. Henan has a population of around 94 million inhabitants (China Statistical Yearbook, 2014). With a per capita GPP of around 34.000 RMB, the Henan province is significantly below the Chinese average which has grown above 42.000 RMB in 2013 (Chinese Statistical Yearbook, 2014). The total budget available for HXI for Henan amounts to slightly over 10 million USD of which 13.8% went to the provincial level and 20.3% to the county of Xi Xian (Evaluation Report of Henan HXI project, CPSM 2015). Xi Xian is one of the 5 counties participating in HXI, out of the total of 109 counties in the province of Henan. It has a population of slightly below 800.000 (Chinese Statistical Yearbook, 2014). Xi Xian covers 1882 km 2, and is densely populated with 420 inhabitants per km2. It hosts 2 central hospitals, 6 county level hospitals, 20 township health centres and 343 village clinics. Prior to HXI, Xi Xian participated in HVIII. Xi Xian has been selected by the province to participate in HXI because of the demonstrated performance and abilities while participating in HVIII.
5.2
ABC Hospital Payment System
This case study regards the implementation of the innovation entitled ABC Hospital Payment System, as implemented in Xi Xian, which is akin to hospital payment reforms in other counties in Henan, such as Yi Yang County. Interestingly, it will become clear from this case study that the Provincial Health Bureau played an important role in the design and implementation of the innovation. The innovation is designed to solve problems which the five HXI counties shared in their baseline situation, and are closely linked with the HXI objectives on hospital payment and service delivery improvement. It addresses the reimbursement system for hospital services, and hence the financial incentives, which were viewed to be an obstacle for hospital service improvement in China at large at the time of the start of HXI, late 2008.
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Hospital payment reform forms an essential component of the national health reform (Zhen 2009) and of HXI. As county level NCMS offices are the prime contractors of hospital services, the innovation can be classified under component 1 of HXI. At the same time, the payment reform is often closely linked with the introduction of standardized clinical pathways and quality management and therefore with component 2 of HXI. In some cases, it even considers integration with public health services (such as monitoring and prevention), linking it with component 3. Hence, hospital payment innovations are a means to shape the comprehensive improvements valued by HXI, as witnessed by the following text from the domestic HXI evaluation (Fudan 2014:65): The exploration of “comprehensive reform” has been used a combination approach of reform in public hospitals, paying attention to the integration in the design and implementation process, focussing on the balance of standard service and control cost balance, emphasizing on the interests and coordination among health care departments, hospitals and patients. Since the end of 2009, the Health XI project developed “clinical pathways” and its corresponding rational compensation mechanism of rural medical institutions in rural areas to fully mobilize the enthusiasm of the medical staff, standardize the medical service, improve the service quality, control the medical costs, improve the operational efficiency of public hospital and the utilization efficiency of NCMS fund, so that the masses could enjoy convenient, safe, high-quality excellent, affordable medical services. Gradually it formed the pilot model that was patient-oriented, standardized service with the clinical path, the comprehensive payment system as the means of controlling costs, improved in regulatory system, powered by incentive mechanism, and supported by information system. In the aspect of regulating medical behavior, controlling costs, and improving service quality, it plays a role of pathfinder.”
As before, this case study doesn’t assess whether these outcomes have been achieved, but rather addresses the structures and processes of innovation as they have develop in the context of the county. To give an impression of the results that have caused Xi Xian to be considered as a best practice by the HXI management, we briefly summarize some of the overall performance results achieved as summarized in the Henan Provincial Health and Family Planning Commission report (October 2014). Table 5.1 reveals that the overall satisfaction for rural health services by man has improved from a low 41.7% of men indicating to be satisfied or very satisfied, to 91.5% providing this satisfaction rating. Table 5.2 shows a similar progress for women. Table 5.3 evidences the reduction in out of pocket payments reported by the province for Xi Xian. While it was low compared to other counties in 2008, at 45.5%, it has been reduced to 12.7%, much lower than all other Henan HXI counties, and the overall HXI average.
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Year
Overall
Henan
Yiyang
Ruzhou
Wuzhi
Qingfeng
Xixian
Health XI average 2008
63.8
65.6
96.9
27.9
87.0
83.7
41.7
2011
71.2
79.6
83.6
59.2
85.0
100.0
82.0
2013
85.4
84.4
93.0
70.1
80.4
91.6
91.5
Table 5.1 Men’s comprehensive satisfaction to rural health service (Henan Provincial Report 2014)
Year
Overall
Henan
Yiyang
Ruzhou
Wuzhi
Qingfeng
Xixian
Health XI average 2008
66.6
71.1
93.1
38.0
86.7
92.7
50.4
2011
72.8
76.9
86.7
58.6
84.0
92.2
81.4
2013
85.5
84.4
92.6
67.9
81.7
94.1
90.0
Table 5.2 Women’s comprehensive satisfaction to rural health service (Henan Provincial Report 2014)
Year
Overall
Henan
Yiyang
Ruzhou
Wuzhi
Qingfeng
Xixian
Health XI average 2008
72.3
66.5
69.9
91.2
71.7
52.7
45.5
2011
49.5
42.1
44.0
47.9
32.8
21.9
43.4
2013
35.6
25.3
29.5
38.2
23.5
26.6
12.7
Table 5.3 Self-paid proportion in hospitalization medical expenses (Henan Provincial Report, 2014)
While, it is a core principle of HXI that innovations are based on county level baseline measurements, it is interesting to note that the provincial Health Bureau has played an important role of laying out a hospital payment framework, which the counties of Yi Yang, Qing Feng, and Xi Xian adapted to their own situation. Respondents explicitly mention the ‘Henan approach’ to consist of ‘balancing quality, 65
costs and the needs of the population’ (thus offering yet another view on comprehensiveness). Henan is unique in their development of the so called ‘ABC system’, built to standardize health care delivery and reimburse on the basis of appropriate standardized health service provisioning: ‘We now have consistent standards’. In this case study we consider the design, implementation, sustainability and dissemination of this system as introduced in Xi Xian.
5.3
Design and first implementation of case based payment
From the start of HXI, Henan and Xi Xian have aspired to implement a “comprehensive approach”, as also advocated by the HXI guidelines. Yet, comprehensiveness is a multifaceted construct, from which different facets are highlighted by different stakeholders, or as time progresses. For instance, it may refer to both outpatients as well as inpatients, or to integration of both public health services and hospital services. More ambitiously, it may refer to the joint consider of quality and costs, and the needs of the population (as stated above) and even to alignment of delivery and reimbursement. The national health reforms and HXI leave room for all these interpretations, and can be viewed to yield expectations for all these interpretations. Respondents highlighted different interpretations and different focus points depending on the context.
Given this multifaceted nature, it was far from straightforward for the province of Henan and the county of Xi Xian to craft an initial design befitting the context and the dynamics of the national health reform. Even at the time of research in 2014, respondents place different emphases in their syntheses of the innovations and innovation process. A prime common denominator of the comprehensiveness lies in the ability of the ABC system to reimbursement hospital services so as to stimulate the joint improvement of quality and costs of service delivery, while servicing according to patient needs. The latter aspects may refer to the fact that overprovisioning of health services was a common practice in China targeted by the reform. Several respondents have indicated that the initial ideas already developed during the participation in HVIII, but that, supported by the national health reform, HXI offered the context and timing required to define and undertake a comprehensive innovation effort: “So, HVIII basically didn’t give a comprehensive intervention. But for the time when we had HXI, it’s like all the pieces were there(…) if there is anything that sets Henan province apart from the projects of the rest of the provinces, it is that we stress the need to find you know a gravity point, a balance point, among the three factors, cost, and quality and also demands.” (Respondent H1) 66
“It is a comprehensive work, not only for instance the single clinical pathway innovation can solve the issue, it needs a comprehensive approach, our experts came up with comprehensive reform….various steps are linked to each other. (….) Business is improved, while human resource and finance cannot catch up with. (….) every reform needs to follow up, only the power of all reforms together cause the impact, so that the efforts reach one plus one to be more than two” (Respondent H2) As may be concluded from the above, the comprehensiveness of the approach also implies the involvement of a variety of stakeholders. County health bureau respondents explicitly refer to the necessity of engaging the many different stakeholders, and have pointed out that a narrow scope will not work.
The initially designed system was a case base payment system, where for each condition a ceiling for the reimbursement per patient was defined to control costs and overprovisioning of services. This system was expected to comprehensively contain reimbursement costs and improve effectiveness and efficiency of service delivery. The NHPFC had issued general clinical pathway guidelines for an initial set of conditions, which provided a framework for (provinces and) counties to duly implement clinical pathways. Moreover, HXI particularly promoted alternative reimbursement models to the feefor-service models, among which reimbursement for the delivery of clinical pathways. Hence, in close cooperation with the provincial health bureau, Xi Xian set about to design an initial case based payment system which matched standardized clinical pathways to treat a class of highly prevalent conditions as advocated by the national health reform. As part of the initial design, the pathways were specified in detail. The initial uptake among hospital management and clinical staff was lower than anticipated, for an important part because of the financial consequences. I was not very supportive for it. (Why was there resistance?) The ceiling price for a single disease is too low. (Respondent H3) The ABC system substituted an important source of revenue for hospitals and staff, provided in the form of fee-for-service charges and drugs mark-ups for highly prevalent conditions, by case based financing, in which medicine prescription was controlled through the pathway definitions. As a result, the criteria for exclusion from the pathways for patients with severe or co-morbid conditions were frequently applied, and the inclusion rates in the pathways were much lower than anticipated.
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At the very start, in 2009, we started to perform the single disease payment promoted by the health ministry. That is the first phase. But few patients met the requirements to be involved in the payment scheme. (Respondent H4) This first phase took most of the years 2009 and 2010.
5.4
Iterative adaptation and stakeholder involvement for the ABC system
The alignment of the innovation with the national health reform and the context of the HXI project aided the provincial and county health bureaus to persist with the comprehensive hospital reform despite these initial difficulties. They increased the efforts to continue the innovation process by iterative adaptations, and eventually brought about an innovation supported by all stakeholders involved, as described in more detail in below.
The clinical pathways as initially designed by Xi Xian lacked service delivery standards and corresponding reimbursement rates for patients for which the efficiently designed standard pathways and corresponding case based payments were unfit. As a result hospital and staff made creative use of the exclusion criteria to counter revenue shortages, and hence the low uptake of the case based payment system. The adaptations which are reported to have remedied these shortcomings go under the name of ABC system.
The ABC system is based upon consensus among stakeholders that the majority of patients with one of the condition for which pathways are introduced, can be adequately served through a standard clinical pathway corresponding to the patient condition. For each condition, this corresponding standard pathway is referred to as pathway A, and the patients whose condition admits applying the standard pathway are classified as A patients. Respondents refer to this class A-pathway as the “basic treatment”. Depending on severity and co-morbidity the basic treatment is considered inappropriate for a minority of patients. Among these remaining patients, there is again a majority which can be served by standardized extensions of the A pathway, resulting in the B pathway, or ‘composite treatment’. Patients which are not classified as A-patients, but whose conditions admit treatment via the B pathway are classified as B patients. The remaining patients receive a ‘special treatment’ and are classified as C patients.’ For each condition and for each of the three classes A, B and C, the ABC system specifies a reimbursement rate to cover the costs of the corresponding standardized pathway. 68
In 2011, we had the ABC, three types of pathways. (..) It was designed on the basis of the guidelines of the health ministry. The guidelines of the ministry are like “this type of medicine is required”, and there are more general. In our pathway, the requirements are like “this very medicine is required”. (..) Our ABC is for payment, while the ministry clinic pathway is for treatment. (Respondent) The ABC pathways initially only regarded inpatients and were based on the national guidelines for clinical pathways. The ABC pathways were initially defined for a restricted set of conditions, which was gradually extended when the approach appeared successful. The incremental development of the ABC pathway system over the years becomes in fact apparent through the increase in the number of pathways, and hence conditions, in place. The initial 2011 ABC system comprised of 14 disease pathways for the THCs and 40 pathways for county hospitals. In 2013 the number of pathways had grown to 56 for THCs and 106 for county hospitals. In 2014, Xi Xian had also introduced 21 pathways for outpatients for hospitals, while additional pathways and adjustments where again being discussed for THCs and even for VCs. (What made the attitude change?) The key here is the NCMS and the negotiation mechanism between the hospital and the NCMS. Before we could only accept the settled price. (..) In the beginning, ceiling price for a single disease was for the whole province, and we did not have the right to set our own price. However, we counties in the project have special policy that we can set our own price in the end. (Respondent H5) The basis of the corresponding reimbursement system is formed by a fixed reimbursement rate per pathway per class (A,B,C), the case based payment. For each condition, the class A reimbursement rate is the lowest, while the class C rate is the highest. The reimbursement amounts are however not solely based on the case based payment. As of 2011, Xi Xian also introduced performance management, and included performance indicators regarding pathway adherence, drug prescriptions, and the percentages of patients classified as A, B and C respectively in the reimbursement. We will address these ‘purchasing innovations’ more extensively below. The agreed percentages of patients to include in each of the A,B, and C classes are referred to as ‘quota’. Defining these quota requires the involvement of and consensus among multiple stakeholders, as the quota interact with conditions, treatment plans, costs, and therefore with medical insurance (premiums), co-payments and with patient demand. The quotas are presently addressed in standard periodic review processes. Figure 5.1 shows that the realized quota have remained stable since March 2012, and that well over 70% of the patients is classified as a Class A patient, while slightly above 5% is classified as C.
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Figure 5.1: Inclusion rates of classes A,B and C since March 2012.
According to HXI reports, the Henan approach has yielded a substantial increase in the clinical pathway coverage and better cost control. The reported inpatient average costs for patient included in the pathways are considerably below the reported HXI averages for inpatient costs over all patients. The reported percentages of out of pocket payments for included patients are also considerably lower than HXI averages, as is already the case for non-included patients. It has been reported that medical efficiency improved, the rate of basic drugs increased to above 95%, the use of antibiotics decreased, while out-of pocket cost didn’t increase. Figure 5.2 shows indeed that the changes in cost per case have been contained to be within 2% over the 24 months since March 2012, while the percentage of out of pocket cost is stable and constant, in contrast to the out of pocket costs for patients with conditions which are not included.
We now briefly mention two examples of further adaptations at the time of research, providing evidence that the ABC system is not static, but that HXI may have set a continuous improvement process in motion which lasts while HXI is finishing. Both patients and staff mentioned the need for a ‘one bill system’ where patients receive one bill per episode rather than a separate bill per service provided. The hospital management is working on such a one bill system, which is also to expected to contribute to further patient flow improvement as it increases the service transparency.
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A second ongoing adaptation regards the quota for class A patients. The provincial health bureau targets a class A quotum of 85% as an objective for further improvement. These targets are discussed in periodic meetings with all relevant stakeholders, in particular the NCMS office and the hospital management, and hence continue to be a topic of negotiation. For instance, the county hospital doubts whether 85% class A inclusion rates are realistic for all (types of) conditions. “In the health bureau, they wanted the pathway to cover more patients. In surgical departments, it may be feasible. Anyway, it is not the same thing to the internal departments. From the perspective of the physicians, the difference between surgery and internal medicine is very large. The health bureau still wants coverage of 85% for the departments. They repeated that some hospital can reach 90%, so we can do the 85% (Respondent H5)
县医院综合支付患者次均费用 3200 3180 3160 3140 3120
Figure 5.2 Average expenditure per admission, May 2012-April 2014, (Presentation Xixian)
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2014年4月
2014年3月
2014年2月
2014年1月
2013年12月
2013年11月
2013年10月
2013年9月
2013年8月
2013年7月
2013年6月
2013年5月
2013年4月
2013年3月
2013年2月
2013年1月
2012年12月
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2012年7月
2012年6月
2012年5月
3181 31803175 3180 31793180318231823180 3162316331583156 31623164 31513146 3142314731443145314731463147
Figure 5.3 OOP spendings for pathway included and non-pathway patients (Xixian County)
The comprehensiveness of the ABC system following the initial designing in 2009 and the subsequent incremental adaptations are summarized as follows by the provincial health bureau: (Evaluation Report of Henan Provincial Health XI Project, 2014): “Comprehensive payment system refers to a new payment system of medical expenses based on quality management, performance contract, comprehensive supervision and classified payment.” The purpose of the reform is to apply the concept, mode and method of comprehensive payment to the basic medical service, promote reasonable allocation of medical resources in rural area, improve service quality and efficiency of grass-root medical institutions, control unreasonable growth of medical expenses and improve the functions of rural health funds, including those of New Rural Health Insurance Scheme and rural medical aid. The guiding principle in this reform is to promote medical insurance operators into strategic buyers of medical service, gradually changing them into active and effective purchasers of basic medical service, by which deal with relationship between the government which proposed medical reform and market, equality and efficiency in a correct and proper way. “ Alternatively, the comprehensiveness is often captured by reference as a “5-in-1” system, comprising: 1) medical quality standard, 2) purchase service, 3) classified payment, 4) comprehensive supervision and 5) computer-aided management. Figure 6.4 provides yet another comprehensive synthesis of the ABC system. The difference syntheses may indicate that while considerable progress appears to have been attained, the innovation is also still a work in progress. Moreover, it signals the complex, multifaceted character of the innovative ABC system.
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机构医疗卫生质量 管理体系框架图
宗旨 方针目标 决策者 院 级
体系纲要 流程文件
职 责 权 限 分 工
目 标 标 准 分 解
文 件 化 体 系
检 查 监 测 改 进 书
操作文件 明 责 说 （工作文件） 法规 职 位 操作说明书 岗 位 案 档 岗 制度 规范 规程 常规 录 痕迹文件 痕迹 电子文档 记录 图标 音频视频 记
职能 部门 临床业 务科室
操作 岗位
Figure 5.4 The Framework for Comprehensive Hospital Reform used in Henan
5.5
Top down and Bottom Up
The initial plans for a comprehensive reform had already been discussed among Xi Xian county health bureau and the provincial health bureau during HVIII, suggesting that the innovation started from a bottom up need. At the same time respondents made clear that the context provided by HXI and the national health reform, and the corresponding objectives for comprehensive reforms, has formed a top down mechanisms to define and start the innovation.
The initial designs of the pathways and case based systems were aided by both international experts and domestic experts accessible through HXI. The hierarchical commitments made by participating in HXI to pilot the national health reform may have been particularly important when the initial designs didn’t bring the aspired results during 2009 and 2010. The continued efforts for innovation appears to have benefitted from various mechanisms among which HXI supervision, access to expert support and 73
the quality of this support, and the intrinsic motivation to succeed by county and provincial level health bureaus. Moreover, in addition to the structure provided by the HXI supervision missions and the reporting structures of HXI at large, the provincial health bureau organized bi-monthly project meetings, attended by the provincial health bureau staff involved as well as attends from each of the 5 HXI counties in Henan. Respondents consider these bi-monthly meetings to have been important communication platforms. Project staff has acknowledges the strong support at county and provincial level. Xi Xian itself organised training for management at various levels.
As further adaptations were made, and the innovation developed, the involvement of physicians and nurses at the grass roots level increased, for instance through their contributions to the design and adaptations of the clinical pathways. Moreover, hospitals have been involved in setting the reimbursement rates paid by the NCMS office, which contributed to reducing resistance to the ABC system at the organisational level. At various stages of the development, bottom up and top down processes have both played valuable roles in the achievements of the ABC system.
5.6
Close collaboration with a network of Experts
The provincial and county health bureaus received technical assistance from international, national and provincial experts. In addition, the provincial health bureau provided support to the county health bureaus for financial and managerial issues. The interactions with the experts started early on as Xi Xian was relatively early to start designing the hospital payment reform, which was considered an important innovation in HXI. As the innovation needed subsequent adaptations to attain the desired results, the interaction with national and provincial experts continued, if not intensified. According to the provincial experts, all 14 national experts were in one way or another involved in Xi County. “The project provided a platform for technical assistance, we had the access to international and also domestic experts. The project also created brainstorm among the team members.” (Respondent H1) The tight cooperation of the county staff, experts, and the provincial team extended into intense longterm collaboration with some of the national and provincial experts. Respondents speak of a ‘network’ where they interactively communicate when needed, putting a structure in place which intensified the formal HXI and provincial meeting structures.
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“Actually, I think [name national expert] and me, we keep in touch frequently. You can have a glimpse for my emails, it’s very often. Because [name national expert] is very interested in this project, in fact, the frequent visits are directly related to the great attractiveness of the project. Because of this interest, now, we communicate in various ways, email, phone….many.” (Respondent H1)
5.7
Alignment of Pay-For-Performance incentives
During 2011, Xi Xian formalized performance based incentives as part of the ABC system, to reward adherence to the defined clinical pathways, drugs prescription guidelines, and negotiated quota. The principles which have been applied can in part be classified as a shared savings model as illustrated by the following example. County hospitals are allowed to keep part of the savings they realize when the actual costs are less than the negotiated reimbursement rates. 60% of the realized savings go to the budgets of the clinical departments, 37% is retained at the central hospital level, and 3% goes to the hospital quality team. These figures are dynamic, for instance the contribution to the quality department had recently been diminished at the time of interviewing. For the 60% of the savings going to clinical department the breakdown is as follows: 55% goes to the chief clinician, 23% to nurses, 4% to department director, 4% to quality control staff, 4% to the nursing director, and 10% to others.
This detailed performance based internal payment system clarifies how county level objectives are translated to organisational, departmental, and personal incentives, thus creating alignment in the reward system. Moreover, we note that the budgets for personal rewards depend on organisational performance, not on individual performance.
As a side effect, respondents are not equally engaged with all of the performance measures influencing their performance based rewards: “I am not working on user satisfaction measures, so I don’t know the scores”. Similarly, we found that the concepts and terminology which were so frequently and intensively exchanged among provincial health bureau staff, county level health bureau staff, and experts involved, were sometimes hardly recognized at the grass roots level. Not all interviewed personnel recognized terms like ‘Health XI’, ‘continuous quality improvement’, or ‘ISO’.
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5.8
A New Role for the NCMS office
The innovations described above rely on two supporting innovations which have been repeatedly mentioned explicitly by respondents. First of all, the NCMS office which had been put in place when the NCMS implementation started earlier this century, developed into an important stakeholder for the county level health bureau, as it had the task of ‘payer’, ’purchaser’ or ’contractor’ in the implementation of the ABC system. The corresponding expanding responsibilities also led the NCMS office to develop a system of controlling the care provisioning, and more specifically, computerized information systems, in alignment with other stakeholders (see also the 5-in-1 approach mentioned above). These systems collect the data required for performance reporting by county hospitals and THCs to the insurers. The operational data are mostly entered by hospital staff, which had no problem demonstrating the use, and was clearly aware of the connection between the pathways, administration, and billing. They were of the opinion that the IT system supports their work and didn’t consider the resulting registration activities to be a burden or a waste.
The new responsibilities didn’t only require from the NMCS office to negotiate about reimbursement rates and performance incentives. The financial management of the NCMS funds, required alignment between the NCMS expenditures for purchased services on the one hand and the revenues from NCMS premiums and government funds on the other hand, in such a way that the resulting available services match local health service demands. The subsequent negotiations and detailing of reimbursement rates, required extensive measurements, analysis, and further communication regarding the health service processes. Hence, the NCMS office had to develop deep operational knowledge regarding treatments and quality of care, in order to ensure access to efficient care of the agreed quality and according to demand. To this purpose, the NCMS office set service quality criteria for various conditions on the basis of national and provincial clinical pathway standards. In consensus with the other local stakeholders involved, it contributed to the subsequent detailed specification of A, B and C pathways and quality criteria. The reimbursement rates were subsequently based on costing of the pathway activities and further negotiation. These purchasing processes, assisted by further piloting when considered appropriate, eventually resulted in procurement contracts between the NCMS office and the county hospitals and THCs.
Hence, we observe that the NCMS played an increasingly important role in the implementation and execution of the ABC system innovation. As decisions regarding reimbursement may easily affect the 76
actual quality of the service, the purchasing role of the NCMS office brings about monitoring and control activities, and indeed setting up reliable information systems to be informed as needed to take up the purchasing responsibilities. As a result, some of the inspection and accreditation responsibilities that previously resided with the health bureau were transferred to the NCMS office. This brings changes in organisational and personnel responsibilities, which were on the agenda at the time of interviewing. Moreover, the changes require new and more knowledge intense competencies from the NMCS office, which has become a pivotal stakeholder in the advancement of the ABC system that now formed the basis for health service reimbursement in Xi Xian. Therefore, the newly required competencies didn’t only regard technical purchasing and health service skills, but also relational coordination skills.
5.9
Reporting and Performance Incentive Effectiveness
The information management - as already discussed in the context of the NCMS contracting - played an important role for internal performance measurement and rewards, and in the reporting to county, prefecture, and provincial health bureaus, and subsequently up to the HXI project management and supervision office. Next to collecting and reporting this information, Xi Xian also has been transparent about the information. Transparency, particularly in the form of public reporting, can play a motivational role which complements pay for performance incentives. Xi Xian combined the two for instance by publishing salaries of hospital staff on the ‘great wall’ at the hospital premises, as well as the performance-based differences. According to our knowledge, this is one of the very first examples where transparency (to patients and all other external stakeholders) has been practiced on this detailed level. Despite this remarkable transparency at individual level, the effects on staff may have been limited as the difference were perceived as relatively modest while interviewed staff often reported to be unaware of the exact relationship between their achievements and the performance related salary.
This qualitative research doesn’t aim or permit to address achievements to innovations. Still some respondents were eager to report that benchmarking within the prefecture reveals that Xi Xian was a relatively poor performer at project start in 2009, while it is ranked best in 2014. While effects on health outcomes are considered to be difficult to establish, the periodically reported process
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indicators within priority areas of the HXI supervision framework have improved since the ABC system became effective in 2011. “For the health outcome indicators, there are many co-variables, attribution analysis is really very difficult. But for some process indicators, like those seven priority areas, you can make that kind of attribution. Like this government procurement of public health care service, the performance pay for public health care service is surely the deliverable of our project, you see, and the performance pay for public health care service etc. things like that, those are related to seven priorities, those are process indicators, yes, you can relate them to HXI, because without HXI, they will surely have not adopt those measures.” (Respondent H1)
5.10 Self-Evidence of Sustainability Although most respondents were fully aware that the ABC system was an HXI innovation, there was no doubt that the ABC system would be sustained after HXI ended. All respondents considered the ABC system to have become an irreplaceable, if not irreversible, part of the county level health system. In addition, many respondents considered the periodic performance reviews and continuous improvements as tightly coupled with the ABC system. The common perception was that not just the sustainability of the achievements as per project end were sustainable, but in fact a dynamic, continuously improving, ABC system.
The interaction HXI has created beyond the county and provincial borders, with experts, and other HXI counties has been made possible through labelled HXI budget for learning and exchange activities. As HXI ends, the exposure to experts and best practices from other counties and provinces as well as international best practices is therefore likely to be reduced and hence to lead to a reduced uptake of new innovations. The absence of an (inter)national project management and supervision may also lead to changes in priorities. “How to say, we can take a real life example. Man gets addicted when he owns car and can drive, which makes him feel very comfortable. He will not want to take the bike anymore when going far way. Then he must create conditions to continue owning a car. But for the speed, whether it remains equally efficient as it is right now - it works very well as it is - that is another thing.” (Respondent H1) Finally, future changes in the composition of the leadership and project team have been mentioned as a factor influencing the sustainability. Already, some of team members have been promoted, and 78
respondents have referred to this ‘evidence’ of the success. At the same time, they recognize that when people change positions, project skills and knowledge can be affected. These developments were considered particularly important because of the changing roles for the NCMS office and the health bureau as an effect of the implemented ABC system.
5.11 Dissemination The provincial project structures have acted as a primary platform for dissemination, where the provincial project counties shared experiences among them, and subsequently to non HXI within Henan. Likewise, XI Xian has received considerable attention within HXI, and contributed to disseminating the ‘Henan approach’ to other HXI provinces and counties. Its achievement have also been recognized by the World Bank who published a report (2013) on Xi Xian’s hospital reform highlighting the improvements in patient satisfaction.
In addition, Xi Xian has received numerous international and national visits from health policy makers and scientists. Especially towards the end of HXI, there has been a continuous flow of visiting delegations. Xi Xian has also presented the ABC system at national health reform workshops to their peers. ‘We are doing well so we have received many visits for training’. Our research has not revealed evidence that the ABC system, or ‘Henan approach’ is currently being implemented beyond the provincial borders.
5.12 Discussion & Conclusions Xi Xian has been one of the three counties in the province of Henan to develop an implementation of the ‘Henan approach’ to comprehensive hospital reform, which eventually developed into the ÁBC system’. The project structures, close collaboration and expert support by the provincial health bureau have been an important factor throughout the duration of HXI. The provincial level also interacted in the communication with national experts, many of which were involved at one moment or another and this cooperation has been very close.
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Although the ABC system has received considerable recognition starting from early 2012, the comprehensive hospital reform which initiated it and was designed in 2009, in alignment with the national health reform and HXI priorities, struggled to be successful until 2011. The case based payment system had difficulty gaining acceptance at service delivery level, causing a low initial uptake. This doesn’t necessarily imply that case based systems are inappropriate. The difficulties appear to have been related with the resistance to give up old revenue models for new and less generous ones, and perhaps with an initial lack of grass roots level involvement. It has taken sustained and collaborative efforts, and several rounds of adaptations before the innovation developed into the ABC system that was accepted among all relevant stakeholders and successfully expanded.
The monitoring and control of the ABC system, which also includes performance management, required novel information systems, which appear to have been implemented without additional difficulties. This enabled a system in which performance was monitored, reported and published. Performance based financial incentives are arranged between NCMS and hospitals and THCs and subsequently boil down to departments and in some cases the individual level. The experienced relationship between personal performance and financial rewards, however, appears to be modest and may form a point of attention for further improvements.
It also appears that the close interactions among all the stakeholders may have resulted in low patient involvement. We have found no evidence that patient have been involved, while some patients reported not to be aware of all the possibilities offered (e.g. with respect to the fund for catastrophic diseases). Overall however, patient satisfaction has increased, and the focus group respondents scored the services from 80 to 110 on a scale from 0 to 100. These figures are confirmed by the HXI benchmark reports on patient satisfaction, which also reports a considerable reduction in out of pocket expenditures for Xi Xian. Patients acknowledged that health services have become more affordable, quality of diagnosis improved, as did the attitudes of health care staff. A young mother announced to be the first in the family able to afford delivery in a hospital. At the same time, patients are aware of the coverage limitations of the NCMS, and the fact that receiving treatment for specific severe diseases might still be difficult, leading to potential tension in the patient provider relationships.
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One might also perceive that the developed ABC system can play a larger role in referring the patient to the provider organisation which addressed their needs most efficiently. In many cases this may entail referral to VC or THC. Extension of the pathways over multiple providers, e.g. hospitals and THCs, or explicit criteria for referral and inclusion may form another direction for future improvement. As patients may have limited trust in VC and THC services, this may also require further service capacity improvement. Altogether, further integration of the service delivery infrastructure can be a valuable next step. This will also require further integration of the information systems. Naturally, such integration needs to be aligned with the other innovations Xi Xian has implemented under HXI and has sustained.
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6. Continuous improvement of public health services in Jiulongpo, Chongqing 6.1
Jiulongpo, Chongqing
Component 3 of HXI regards public health services, among which services aimed at prevention. The existing health system in 2008 hardly reimbursed preventive services, and preventive services were believed to assist health service cost containment and improve health. Public health services, and in particular preventive services have therefore been explicitly prioritized to be equalized with traditional curative services by the National Health Reform. This case study analyses the implementation of public health service innovations in the district Jiulongpo, in the municipality of Chongqing. While Jiulongpo has implemented many public health service innovations, this case study rather emphasizes the underlying innovation of continuous improvement.
Chongqing forms one of the five national central cities in China. Jiulongpo is located south west of the city centre of Chongqing. It has a history as a mining district, while industry plays a main role in its current economy. The total surface of Jiulongpo is 442 km2, of which 362 km2 is considered as rural. This is remarkable as Chongqing is sometimes known as ‘the largest city in the world’ or ‘LA of the East’. Jiulongpo thereby embodies the transition from an agricultural economy to industrial (and service) economy which takes place at unprecedented speed in Chongqing. In 2013, the population of Chongqing is estimated to be around 29 million, two third of which are considered as rural. One of the societal priorities of Chongqing has been to control the migration of the rural population to the city of Chongqing proper and other cities, for instance through the Hukou system. Jiulongpo consists of 11 towns; 8 administrative units [streets]; 106 administrative villages; 107 neighbourhood communities and 11 community centers. Its population is 1.141 million, and about 185,000 of them are farmers. The average yearly net income is 13,145rmb per capita (2013). Jiulongpo has a central THC next to eight other THCs and about 80 VCs. 457 health care workers are employed at township level, while there are 123 village doctors.
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In a condensed form, Jiulongpo is confronted with the societal problems taking place in the municipality Chongqing and the People’s Republic of China at large: the urban/rural gap, migration from rural to urban, and the existence of many vulnerable groups. According to the Jiulongpo health information, the specific needs of local residents are the large incidence of gastro-intestinal diseases, measles, non-communicable diseases (NCD’s) such as hypertension and diabetes, TB, HIV and mental health care.
The delivery of five public health services involves the following five stakeholders 1) health inspection; 2) the local centre for disease control (CDC); 3) the centre for maternal and child care; 4) mental health care facilities; 5) public health management centre.
Initially, Jiulongpo was not selected by the municipality for participation in HXI. According to the director of the health care bureau as well as the mayor, they have pleaded to join the project because they believed in its objectives and approach, and were motivated to make a difference in rural health care delivery. Being a HVIII participant, Jiulongpo can not only be considered as motivated but also as an experienced participant of World Bank Health projects. In HVIII, it compiled a standard for workload benchmarking, which was edited as a book in cooperation with Chongqing Medical University and has been used nationally. Jiulongpo made explicit arrangements to keep experience project staff involved, even after retirement.
6.2
Baseline Measurement and the ‘Continuous Improvement’ Innovation
The baseline assessment with which each of the participating counties started of their HXI activities, identified seven priority populations for public health interventions as well as 70 priority items. The seven populations are:
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1)
elderly,
2)
maternity care
3)
new-borns,
4)
hypertension patients
5)
diabetes, patients
6)
disabled persons
7)
mental health.
The approach Jiulongpo took to HXI didn’t emphasize a specifically implemented innovation, whether it be for one of the populations or priority items, or comprehensively covering several of them, but rather to learn how to intervene effectively, how to improve. Local government and health bureau staff as involved in HXI characterize HXI as ‘Not the different achievements of this and that, but a new way of thinking’. The Jiulongpo intervention is not a single loop learning process, e.g. learning clinical pathways or performance measurement, but targets a double loop learning process: learning to learn, learning to improve. The second loop is to repeat implementing new innovations, or new intervention, for a new improvement opportunity when a preceding one has been completed. “The biggest success of the project is not about specific activities. More importantly, the project helped us to change the mindset, to have new ways of doing things. We learned new evaluation tools. It is like the project gave us a key that can open different doors. (…) To put it another way, the National Health Reform points a main destination, HXI helped to find a roadmap to reach to destination. Whatever we do /now, we refer to the methods that we learned from HXI that we first identify issues, solve the issue, evaluate it and assess the issue again and improve it until you are satisfied. (Respondent J1) Jiulongpo refers to the continunuous improvement methods that has been learned in a variety of metaphors such as ‘master key’ and ‘roadmap’. It consider these methods as the most important lessons of the project. Within these methods, the continuous improvement refers to the never ending improvement process of identifying an area for improvement through (base line) measurement, analysing the situation, developing a solution, implementing it, and measure again.
With reference to component 3 regarding public health services, HXI is considered to have ‘changed the mindset’ and ‘accelerated the quality of public health services and awareness of residents’ by focusing on public health and prevention as opposed to service delivery for treatments of the ill. As 84
illustrated in Tables 6.1, considerable improvements on a variety of specific public health service processes and outcomes corroborate the claims on general improvement abilities obtained. These and other improvements are the results of various targeted innovations, within the continuous improvement process.
Table 6.1 Public Health Indicators in Jiulongpo (Office for Chongqing Health XI Project Group, 2014)
HXI has also enabled improvements in human resource capacity for public health. The ratio of public health staff was 1 per 1000 population before the Health XI project. It was 1.4/1000 in 2009 and has grown to 1.7/1000 in 2012. Moreover, the available HXI funds for investments in clinics have led to renovation and standardization of village clinics over the last years. In addition, a management information system has been implemented in the village clinics, focused on documentation and reporting.
6.3
Public Health Service Innovations
One of the objectives of HXI, made explicit through the HXI performance indicators, is the per capita spending on public health. This objective became partly redundant when the national health reform 85
specified increases in governmental per capita funding to a level of 35 RMB. In Jiulongpo, the per capita funding was topped by 6 RMB for both the rural and urban population to a level of 15 RMB in 2009. It further increased over the years 2010-2014 to respectively 20, 29, 33.5 and 38 RMB; above the national target.
The thus available funds were in part invested to provide public health services which were freely accessible to (sub) populations. An example of such a freely accessibly public health service is a free health check-up for the elderly, as it was initiated in 2011. In the initial design of this innovation of providing freely accessible (preventive) public health services, the access was arranged and administered via the distribution of health service coupons. In a later stage this design was adapted, improved, when all rural residents were provided a health service card. The introduction of the cards has been reported to have raised the operational efficiency and lowered administration cost. The number of patients making an appointment for the free health check-ups has been reported to steadily increase from 550 in 2011 to 880 in 2013. Health bureau staff indicates that the in addition to the check-ups by appointment, many check-ups are provided to walk-in patients. Although the formal age cap is 65, the focus group respondents younger than 65 also had received a free health check-up. (This may raise questions about effectiveness.) The focus group respondents clearly appreciate the fact that the health check has zero costs and feel that they are wasting that opportunity if they do not go. (..) In the past, patients received physical checkup passively, now they actively ask to be checked up. In the past, we have to visit houses to do checkup and followup, now patients come to visit the community health centers themselves. (Respondent J2)
In comparison to the the total population of Jiulongpo, which exceeds one hundred, the potential for further increase of the number of check-ups is still considerable.
Figure 6.1 provides an illustration of a national guideline implemented in Jiulongpo to initiate treatment of a chronic NCD of hypertension after health check-up. The treatment of NCDs as it may follow from a free health check-up subsequently also involves self-management by the patients. Jiulongpo has piloted free service card based services to support self-management, however found that raising compliance by patients has been difficult. 86
Step
1:
Baseline survey; promotion
baseline
survey,
making
Screening; promotion
appointment,
Selection of management Making reservation 1.
Hypertension
under
Making new reservation for absent
management Registration and health file Step 2: physical examination;
1.SBP≥
180 mmHg
2.DBP≥110 mmHg
health file creating; follow-up Hypertension test
Emergency
Blood
1. Physical examination
sugar
(annually);
3.Change
in
conscientiousness 4.Severe headache or
supportive
dizziness
examination
ECG
5.Nausea and vomitting
1.
Collect the records; creating the
1. Referral after emergency
records
treatment
BP
