背景:初级卫生保健(PHC)的不平等已成为全球卫生不平等的关键问题,要求政府实施适合社区需求和能力的政策。然而,PHCs的基于地点的设施维度在当前的医疗保健文献中被过度简化,在不了解社区社会空间动态的多重影响的情况下,制定以公平为导向的PHC空间规划仍然具有挑战性,尤其是在偏远地区。这项研究旨在通过对社区环境对不均衡的初级医疗保健供应的影响进行细致入微和动态的理解,进一步推动PHC研究的边界。
方法:以水城为中心,中国西南部的一个偏远农村地区,这项基于村庄的研究包括多个数据,即,设施级医疗保健统计数据(2016-2019年),统计年鉴,WorldPop,和中国GDP的空间分布数据。我们使用人均医生数量和基本设备来评估村庄的PHC服务能力,这是中国PHC交付的主要组成部分。描述社区环境的指标是根据现有文献和中国的规划范式选择的,包括乡镇和村级因素。基尼系数和局部空间自相关分析用于显示PHC容量的差异,采用多层次回归模型和(异质)差异模型来检验社区环境的驱动作用和政策干预下的动态。
结果:尽管总体上有所改善,PHC不平等在偏远农村地区仍然很严重。村庄的位置,老化,地形,民族自治,经济条件显著影响村级初级保健能力,而城镇一级的人口特征和医疗保健服务也很重要。尽管它可能会改善乡村诊所的硬件设置(coef。=0.350),最近的以公平为导向的政策尝试可能会加速农村医生的流失(coef。=-0.517)。值得注意的是,PHC与社区环境之间的关联受到此轮政策干预的影响不一致.住院服务能力较高的城镇医疗中心(coef。=-0.514)和更多持证医生(coef。=-0.587)和护士(coef。=-0.344)可能表明更有害的政策效果,减少了乡村医生的数量,而拥有更专业设备的中心(coef。=0.504)和护士(coef。=0.184)有利于改善诊所的硬件设置。
结论:研究结果表明,PHC不平等越来越成为社会共同作用的结果,经济,和近年来的体制力量,强调PHC资源分配机制的复杂性增加。因此,我们声称有必要在PHC交付中纳入对社区定位的更广泛理解,特别是社区空间透镜的跨学科知识,支持其可持续发展。我们的研究结果也为中国正在进行的初级医疗改革提供了及时的政策见解。
BACKGROUND: Unequal access to primary healthcare (PHC) has become a critical issue in global health inequalities, requiring governments to implement policies tailored to communities\' needs and abilities. However, the place-based facility dimension of PHCs is oversimplified in current healthcare literature, and formulating the equity-oriented PHC spatial planning remains challenging without understanding the multiple impacts of community socio-spatial dynamics, particularly in remote areas. This study aims to push the boundary of PHC studies one step further by presenting a nuanced and dynamic understanding of the impact of community environments on the uneven primary healthcare supply.
METHODS: Focusing on Shuicheng, a remote rural area in southwestern China, multiple data are included in this village-based study, i.e., the facility-level healthcare statistics data (2016-2019), the statistical yearbooks, WorldPop, and Chinese GDP\'s spatial distribution data. We evaluate villages\' PHC service capacity using the number of doctors and essential equipment per capita, which are the major components of China\'s PHC delivery. The indicators describing community environments are selected based on extant literature and China\'s planning paradigms, including town- and village-level factors. Gini coefficients and local spatial autocorrelation analysis are used to present the divergences of PHC capacity, and multilevel regression model and (heterogeneous) difference in difference model are used to examine the driving role of community environments and the dynamics under the policy intervention.
RESULTS: Despite the general improvement, PHC inequalities remain significant in remote rural areas. The village\'s location, aging, topography, ethnic autonomy, and economic conditions significantly influence village-level PHC capacity, while demographic characteristics and healthcare delivery at the town level are also important. Although it may improve the hardware setting in village clinics (coef. = 0.350), the recent equity-oriented policy attempts may accelerate the loss of rural doctors (coef. = - 0.517). Notably, the associations between PHC and community environments are affected inconsistently by this round of policy intervention. The town healthcare centers with higher inpatient service capacity (coef. = - 0.514) and more licensed doctors (coef. = - 0.587) and nurses (coef. = - 0.344) may indicate more detrimental policy effects that reduced the number of rural doctors, while the centers with more professional equipment (coef. = 0.504) and nurses (coef. = 0.184) are beneficial for the improvement of hardware setting in clinics.
CONCLUSIONS: The findings suggest that the PHC inequalities are increasingly a result of joint social, economic, and institutional forces in recent years, underlining the increased complexity of the PHC resource allocation mechanism. Therefore, we claim the necessity to incorporate a broader understanding of community orientation in PHC delivery, particularly the interdisciplinary knowledge of the spatial lens of community, to support its sustainable development. Our findings also provide timely policy insights for ongoing primary healthcare reform in China.