Distribution of health care resources in Mongolia using the Gini coefficient

The impact of the scale and hierarchical structure of health human resources on the level of medical services-based on China's four major economic regions

BACKGROUND

Ensuring that the scale and hierarchical structure of health human resources are rational, and that medical services are efficient and fair, is an important task of practical significance. On this basis, examining the impact of health human resources on the level of medical services presents a new and formidable challenge. This study aims to delve into how the scale and hierarchical structure of health human resources in China's four major economic regions affect the fairness and efficiency of medical services, and to identify optimization strategies.

METHODS

This study utilizes provincial panel data from China's four major economic regions spanning the years 2009 to 2021. Initially, it provides a statistical description of the current state of health human resources and the level of medical services. Subsequently, it employs a fixed-effects model to analyze the impact of the scale and hierarchical structure of health human resources, as well as their interactive effects, on the fairness and efficiency of medical services, and discusses the interactive mechanisms between medical service fairness and medical service efficiency. Furthermore, after conducting a comprehensive evaluation of the level of medical services using the entropy weight method, it explores the regional heterogeneity and temporal dynamics in the influence of the scale and hierarchical structure of health human resources on the level of medical services. Finally, the study examines the scientific validity and rationality of the research findings through various robustness checks, including the substitution of research variables and models.

RESULTS

The study found that the scale of health human resources has a promoting effect on the equity of medical services (β ≤ 0.643, p ≤ 0.01), but exhibits an inhibitory effect on the efficiency of medical services (β ≥ -0.079, p ≤ 0.1); the hierarchical structure of health human resources shows a positive impact on both the equity and efficiency of medical services (βequity ≤ 0.160, p ≤ 0.01; βefficiency ≤ 0.341, p ≤ 0.05); at the same time, the results indicate that the interactive effect of the scale and hierarchical structure of health human resources promotes equity in medical services (β = 0.067, p ≤ 0.01), but restricts the efficiency of medical services (β ≥ -0.039, p ≤ 0.01); the mechanism by which health human resources affect the level of medical services in China's western and northeastern regions is more pronounced than in the central and eastern regions; after the implementation of the "Healthy China 2030" Planning Outline, the role of health human resources in the level of medical services has been strengthened; in the robustness tests, the model remains robust after replacing the core explanatory variables, with R2 maintained between 0.869 and 0.972, and the dynamic GMM model test shows a significant second-order lag in the level of medical services (βequity ≤ 0.149, p ≤ 0.01; βefficiency ≤ 0.461, p ≤ 0.01); the channel test results prove that managerial personnel and other technical personnel are key pathways in regulating the impact of medical staff on the level of medical services.

CONCLUSION

This study provides an in-depth analysis of the impact of health human resources on the level of medical services, revealing that both the scale and hierarchical structure of health human resources significantly affect the equity and efficiency of medical services. Furthermore, the influence of health human resources on the level of medical services exhibits regional heterogeneity and temporal characteristics. Robustness tests ensure the scientific validity and robustness of the research conclusions. This provides effective references for optimizing the allocation of health human resources and improving the level of medical services.

The allocation and utilization efficiency of hospital beds in Sichuan Province, China

OBJECTIVE

To analyze the allocation and utilization efficiency of hospital beds in Sichuan Province, China, and to provide a scientific basis for improving the rational allocation and efficient utilization.

METHODS

The supply and demand balance method, health resource agglomeration degree (HRAD), bed efficiency index and bed utilization model were used to evaluate the allocation and utilization efficiency of hospital beds in Sichuan Province from 2017 to 2021.

RESULTS

The number of hospital beds per 1000 population in Sichuan Province increased from 4.97 in 2017 to 5.94 in 2021. The overall supply and demand ratio of hospital beds in Sichuan Province is between 0.85 and 1.01, and the supply and demand situation is a basically balanced situation. The HRAD of hospital beds in Ya'an, Aba, Ganzi and Liangshan is <1, indicating that the equity of hospital beds by geography in these regions is low. The difference between HRAD and population agglomeration degree (PAD) in 9 regions, including Deyang, Aba, Ganzi and Liangshan, is <0, indicating that there are insufficient hospital beds in these areas relative to the agglomerated population. The bed efficiency index of hospital beds in 17 regions, including Chengdu, Zigong, Aba and Ganzi, are all <1, which means that hospital beds are operating with low efficiency. The bed utilization model of Panzhihua is efficiency type, that of Zigong, Deyang and Ziyang is pressure bed type, and that of Nanchong and Ya'an is idle type.

CONCLUSION

The hospital bed allocation in Sichuan Province is relatively good, and the supply and demand situation is in a basically balanced situation. The hospital bed allocation in Aba, Ganzi and Liangshan is insufficient by geography and population. The overall operational efficiency of hospital beds is low, and there are more idle and pressure bed utilization models.

Spatial distribution patterns of human resources allocation in maternal and child healthcare institutions in China from 2016 to 2021

BACKGROUND

In China, economic, urbanization, and policy differences between the eastern and western regions lead to uneven healthcare resources. This disparity is more pronounced in the west due to fewer healthcare personnel per thousand individuals and imbalanced doctor-to-nurse ratios, which exacerbates healthcare challenges. This study examines the spatial distribution of human resources in maternal and child healthcare from 2016 to 2021, highlighting regional disparities and offering insights for future policy development.

METHODS

The data were sourced from the "China Health and Family Planning Statistical Yearbook" (2017) and the "China Health and Health Statistics Yearbook" (2018-2022). This study utilized GeoDa 1.8.6 software to conduct both global and local spatial autocorrelation analyses, using China's administrative map as the base dataset.

RESULTS

From 2016 to 2021, there was an upward trend in the number of health personnel and various types of health technical personnel in Chinese maternal and child healthcare institutions. The spatial distribution of these personnel from 2016 to 2021 revealed clusters characterized as high-high, low-low, high-low and low-high. Specifically, high-high clusters were identified in Guangxi, Hunan, Jiangxi, and Guangdong provinces; low-low in Xinjiang Uygur Autonomous Region and Inner Mongolia Autonomous Region; high-low in Sichuan province; and low-high in Fujian and Anhui provinces.

CONCLUSIONS

From 2016 to 2021, there was evident spatial clustering of health personnel and various health technical personnel in Chinese maternal and child healthcare institutions, indicating regional imbalances.

Gender difference of geographic distribution of physicians in Japan: three-point analysis of 1994, 2004 and 2014

BACKGROUND

Japan's medical education system produces 9,000 graduates annually. Despite the government's implementation of several strategies, including increasing the number of doctors trained, the country still struggles with a shortage of physicians in rural areas. This study examined this issue, focusing on gender and considering years of physician experience, demographic and geographic factors.

METHODS

We analyzed the Physician Census from 1994, 2004, and 2014, examining data on physicians' gender and the number of years since licensure. To correct the impact of municipal mergers, the analysis was aligned with the number of municipalities in 2014 (1741). We examined data from each physician (gender and years of medical experience) and analyzed the demographic and geographic distribution trend using Spearman correlation coefficients. We then used the Gini coefficient to evaluate the distribution change of physicians based on gender and years of experience.

RESULTS

The number of physicians increased 1.29-fold over the 20-year observation period (1.23-fold for male physicians and 2.17-fold for female physicians), and the percentage of female physicians increased from 13.4% to 20.4%. We found that 87.7% of physicians were concentrated in the top 1/3 municipalities in terms of population. The number of female physicians was higher at 91.8% compared to 86.8% for male physicians. The Gini coefficients were lower for veteran physicians of both sexes than for younger physicians. The Gini coefficient for all physicians was 0.315-0.298-0.298 (male physicians: 0.311-0.289-0.283, female physicians: 0.394-0.385-0.395) The Gini coefficients for female compared to male physicians were higher in all age groups, showing that The distribution of female physicians is skewed toward urban areas.

CONCLUSION

Female physicians are less distributed in rural areas than male physicians. In addition, despite the fact that the number of female physicians has increased more than male physicians over the past 20 years, the geographic ubiquity of female physicians has not improved. Since the trend of increasing the number of female physicians is expected to continue in the future, it is necessary to take some measures, such as providing a work-life balance suitable for female physicians.

Examining coordination and equilibrium: an analysis of supply index and spatial evolution characteristics for older adult services in Zhejiang Province

Objective

This study aims to analyze the spatial distribution and dynamic evolution of older adult service supply in Zhejiang Province from 2010 to 2019. Additionally, this research seeks to propose an optimized resource allocation strategy for older adult care services, promoting regional fairness and coordinated development.

Methods

To evaluate the older adult service supply capacity, this research first constructed an evaluation index system based on the Chinese modernization development pattern. Then, an empirical analysis was carried out using a combination of the entropy-TOPSIS method, kernel density estimation, Markov chain analysis, Dagum Gini coefficient, and panel regression model.

Results

The results show an overall upward trend in the supply and service capacity of older adult care in the whole province. However, the spatial distribution of older adult service supply capacity in Zhejiang Province still exhibits a gradient effect, even in the most recent year of 2019. Furthermore, the supply capacity of older adult services shifted to a higher level in the whole province, and regions with high supply capacity had a positive spillover effect on adjacent regions. The overall difference in the older adult service supply capacity of the province showed a decreasing trend. The level of economic development, urbanization rate, transportation capacity, the level of opening up, and the proportion of employees in the tertiary industry had a significant impact on the supply capacity and spatial difference of older adult services.

Conclusion

From the findings, this study puts forth countermeasures and suggestions to optimize the spatial distribution of older adult care services. This includes giving full play to the regional spatial linkage effect, promoting new-type urbanization construction, upgrading the transportation network, and expanding the opening up of the industrial structure. By implementing these measures, a more equitable and coordinated older adult services system can be developed in Zhejiang Province.

Distribution of nursing workforce in the world using Gini coefficient

INTRODUCTION

Unequal Access to human resources for health, reduces access to healthcare services, worsens the quality of services and reduces health outcomes. This study aims to investigate the distribution of the nursing workforce around the world.

METHODS

This is a descriptive-analytical study, which was conducted in 2021. The number of nurses and world populations was gathered from World Health Organization (WHO) and The United Nations (UN) databases. The UN has divided world countries based on the Human Development Index (HDI) into four categories of very high, high, medium and low HDI. To investigate the distribution of the nurses around the world, we used the nurse population ratio (per 10,000 population), Gini coefficient, Lorenz curve and Pareto curve.

FINDINGS

On average, there were 38.6 nurses for every 10,000 people in the world. Nations with the very high HDI, had the highest nurse/population ratio (95/10,000), while the low HDI nations had the lowest nurse/population ratio (7/10,000). Most nurses around the world were females (76.91%) who were in the age group of 35-44 (29.1%). The Gini coefficient of nations in the each four HDI categories varied from 0.217 to 0.283. The Gini coefficient of the nations between the four HDI categories was 0.467, and the Gini coefficient of the whole world was 0.667.

CONCLUSION

There were inequalities between countries all over the world. Policymakers should focus on the equitable distribution of the nursing workforce across all local, national and regional levels.

The allocation and fairness of health human resources in Chinese maternal and child health care institutions: a nationwide longitudinal study

BACKGROUND

In response to an aging population, the Chinese government implemented the three-child policy in 2021 based on the comprehensive two-child policy. With the implementation of the new birth policy, people's maternal and child health (MCH) needs will also increase. The allocation and fairness of MCH human resources directly affect people's access to MCH services. The purpose of this study is to analyze the allocation of health human resources in Chinese maternal and child health care institutions, evaluate the fairness of the allocation, to provide a reference for the rational allocation of MCH human resources.

METHODS

The data of health technicians, licensed (assistant) physicians, and registered nurses in maternal and child health care institutions nationwide from 2016 to 2020 were included. The health resource density index (HRDI) is used to evaluate the allocation level of MCH human resources. The Gini coefficient (G) and Theil index (T) are used to evaluate the fairness of the allocation of MCH human resources from the perspectives of population and geographic area.

RESULTS

From 2016 to 2020, the average annual growth rate of the number of health technicians, licensed (assistant) physicians, and registered nurses in Chinese maternal and child health care institutions was 7.53, 6.88, and 9.12%, respectively. The Gini coefficient (G) of the three types of MCH human resources allocated by population were all below 0.23, and the Gini coefficient (G) allocated by geographical area were all above 0.65. The Theil index (T) of the three types of MCH human resources allocated by population was all lower than 0.06, and the Theil index (T) allocated by geographical area was all higher than 0.53. In addition, the three types of MCH human resources allocated by population and geographic area contributed more than 84% of the Theil index within the group (T_intra) to the Theil index (T).

CONCLUSIONS

China's MCH human resources were fair in terms of population allocation, but unfair in terms of geographical area allocation. In the future, more attention should be paid to the geographical accessibility of MCH human resources, and the allocation of resources should comprehensively consider the two factors of serving the population and geographical area.

Regional disparities and influencing factors of high quality medical resources distribution in China

BACKGROUND

With the gradual increase of residents' income and the continuous improvement of medical security system, people's demand for pursuing higher quality and better medical and health services has been released. However, so far little research has been published on China's high quality medical resources (HQMR). This study aims to understand the spatiotemporal variation trend of HQMR from 2006 to 2020, analyze regional disparity of HQMR in 2020, and further explore the main factors influencing the distribution of HQMR in China.

METHODS

The study selected Class III level A hospitals (the highest level medical institutions in China) to represent HQMR. Descriptive statistical methods were used to address the changes in the distribution of HQMR from 2006 to 2020. Lorentz curve, Gini coefficient (G), Theil index (T) and High-quality health resource density index (HHRDI) were used to calculate the degree of inequity. The geographical detector method was used to reveal the key factors influencing the distribution of HQMR.

RESULTS

The total amount of HQMR in China had increased year by year, from 647 Class III level A hospitals in 2006 to 1580 in 2020. In 2020, G for HQMR by population was 0.166, while by geographic area was 0.614. T was consistent with the results for G, and intra-regional contribution rates were higher than inter-regional contribution rates. HHRDI showed that Beijing, Shanghai, and Tianjin had the highest allocated amounts of HQMR. The results of the geographical detector showed that total health costs, government health expenditure, size of resident populations, GDP, number of medical colleges had a significant impact on the spatial distribution of HQMR and the q values were 0.813, 0.781, 0.719, 0.661, 0.492 respectively. There was an interaction between the influencing factors.

CONCLUSIONS

China's total HQMR is growing rapidly but is relatively inadequate. The distribution of HQMR by population is better than by geography, and the distribution by geography is less equitable. Population size and geographical area both need to be taken into account when formulating policies, rather than simply increasing the number of HQMR.

Sickness absence among employees of healthcare organizations in the public sector in Mongolia: A cross-sectional study

OBJECTIVES

This study aimed to understand the rate of sickness absence (SA) among employees of public healthcare organizations in Mongolia, to identify factors associated with long-term SA, and to estimate costs due to SA.

METHODS

This cross-sectional study included employees of public healthcare organizations who had certified SA from 2016 to 2018. Sociodemographic and occupational characteristics of absentees and the data on absences were collected. A logistic regression analysis was performed to identify factors associated with long-term SA (≥15 days) among employees who had SA. Absence parameters and the average costs due to SA were calculated and the total cost due to SA at all public healthcare organizations was estimated.

RESULTS

From 2016 to 2018, there were 13 653 absentees and 21 043 SA, and the absence rate was 0.9%. The average absence length per absence and absentee were 9.63 days and 14.85 days, respectively. Factors associated with long-term SA were age ≥40 years, 10-19 years in employment, working at the second and tertiary levels, and night shift. The average cost per absentee was 295.5 USD, and the estimated total cost for all health organizations was 1 796 993 USD per year.

CONCLUSIONS

The absence rate was 0.9% and older age, longer work experience, higher organizational level, and night shift were associated with taking a long-term SA. To reduce the costs of absenteeism and promote the health of employees in healthcare organizations, policymakers should review the policies related to SA and develop national guidelines on SA for employers, healthcare managers, and employees.

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

BACKGROUND

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

METHODS

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

RESULTS

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

CONCLUSIONS

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

Impact of the increase in the number of community pharmacists on their geographical distribution in Japan: a retrospective survey

BACKGROUND

Appropriate distribution of health care resources is required to adjust regional disparities in the quality of health care. Besides, the number of community pharmacists in Japan has increased recently, but the impact of this increase on the distribution of community pharmacists is unknown. Thus, we aimed at investigating the effect of the increase in the number of community pharmacists on the distribution per population and per area of inhabitable land.

METHODS

Data from 2008 to 2018 were used. Equity among municipalities in the number of community pharmacists per population and per area of inhabitable land was assessed using the Gini coefficient. A mosaic plot was used to demonstrate the relationship between the population density and increase in the number of community pharmacists per municipality.

RESULTS

The number of community pharmacists increased by approximately 1.3-fold from 2008 to 2018 in Japan. The Gini coefficient per population decreased gradually, whereas that per area increased slightly, with no change in distribution per area of inhabitable land. The number of community pharmacists per population increased regardless of the population density, but this increase per area was smaller for lower population density groups and larger for higher population density groups.

CONCLUSION

The increase in the number of community pharmacists has improved the distribution of community pharmacists per population, but not that per area of inhabitable land. The maldistribution of community pharmacists per area implies an imbalance in the distance between pharmacies and residents. Thus, there is need for measures to improve the distribution of community pharmacists.

Research on the Equity and Influencing Factors of Medical and Health Resources Allocation in the Context of COVID-19: A Case of Taiyuan, China

COVID-19 has killed millions of people worldwide. As a result, medical and health resources continue to be strained, posing a great threat to people’s safety and economic and social development. This paper built the index system of influencing factors of medical and health resources containing the economy, population and society, and then classified Taiyuan into three types of regions by cluster analysis. The Gini coefficient, Theil index and agglomeration degree were then used to analyze the spatial distribution of medical and health resources allocation, and its influencing factors were studied by grey relational analysis. It was found that the population allocation of medical and health resources in Taiyuan was better than area allocation. Population has the greatest influence on the allocation of medical and health resources, followed by society and the economy. The more developed the regional economy, the more diversified the main influencing factors, and the more adjustment and control choices of medical and health resources allocation. Suggestions for optimal allocation were put forward in order to fully utilize the limited medical and health resources, effectively respond to the epidemic needs, promote the sustainable development of resources, protect the health of residents, and improve social benefits.

Exploring the Efficiency of Primary Health Care Provision in Rural and Sparsely Populated Areas: A Case Study from Mongolia

Mongolia is facing serious challenges in the health sector and the macro-economic sphere that have important implications for health financing and to complete universal health coverage. In this context, improving the efficiency of primary health care facilities appears as a critical issue. We study the efficiency of Soum Health Centres (SHCs), that provide primary care in rural Mongolia. Based on activity and resources data collected for all SHCs of Mongolia in 2017 and 2018 we estimate bias-adjusted efficiency scores. A double bootstrap truncated regression procedure is then used to study the factors associated with SHCs’ efficiency. On average, SHCs could potentially engage in the same activity while reducing overall resource use by around 23%. A comparatively higher population density and dependency ratio in the district where they are located tend to favour SHCs’ efficiency. Conversely, the higher the poverty rate in the soum, the lower the efficiency. We find a positive association between SHCs’ efficiency and the proportion of doctors in the health workforce. The human resources allocation process and the capitation formula currently used to pay SHCs should be adjusted based on the size and socioeconomic/demographic characteristics of the population living in the catchment area of SHCs.

Inequality trends in the distribution of healthcare human resources in eastern Iran

Background

Inequitable distribution of human resources in healthcare is one of the main obstacles to improve any health system. This study aimed to evaluate inequalities in the distribution of human resources in healthcare in South Khorasan Province, Iran.

Methods

We have investigated three types of health staff (i.e. nurses, general practitioners, and specialists) from 2013 to 2018. Data were collected from the annual reports of the Statistical Centre of Iran. The Gini coefficient and time trend regression were applied to measure the inequality.

Results

The distribution of specialists and general practitioners were the highest and lowest inequality, respectively. Inequalities in the distribution of nurses and specialists have decreased from 2013 to 2018, while the Gini coefficients of the general practitioners have increased from 0.31 to 0.38. According to the regression analysis, inequality in the distribution of nurses and specialists was decreasing over the time; however, the decline was only significant for specialists. While the coefficient B for general practitioners is positive, this indicates raised inequality, but the observed increase was not significant.

Conclusions

This study revealed that Iran, similar to several other low- and middle-income countries, is with faced the challenge of inequitable distribution of human resources in healthcare, which in turn indicates the necessity of reforms at national and regional levels to address inequalities in the distribution of healthcare human resources, particularly in South Khorasan Province. Hence, the main policy recommendation is to focus on continuous monitoring and evaluation of resource allocation in South Khorasan Province to reduce inequalities.

Disparities in outpatient and inpatient utilization by rural-urban areas among older Mongolians based on a modified WHO-SAGE instrument

Background

Mongolia has made significant progress towards achieving Universal Health Coverage (UHC), but there are still challenges ahead with population ageing and non-communicable diseases (NCDs). The purpose of this study was to investigate patterns and determinants of outpatient and inpatient health service use amongst older people in Mongolia.

Methods

Data were collected using a questionnaire developed for the World Health Organization’s Study on global AGEing and adult health (WHO SAGE). There were 478 participants from rural areas and 497 participants from Ulaanbaatar (further divided into 255 ger/yurt district and 242 apartment district residents). Multivariable logistic regression analyses were used to investigate determinants of outpatient and inpatient health service use with reported adjusted Odds Ratios (AORs) and 95 % Confidence Intervals (CIs).

Results

Participants were aged 60 to 93 years. About 55 % of respondents used outpatient services in the past 12 months and 51 % used inpatient services in the past three years. Hypertension was the most common reason for health service use. Rural residents had longer travel times and were more likely to incur out-of-pocket expenditure (OOP). Multivariable logistic regression revealed that women were more likely to use outpatient services (AOR 1.88; 1.34-2.63). Compared to apartment residents in urban areas, ger residents in urban areas were less likely to use outpatient services (AOR 0.54; 0.36-0.83). There was no statistically significant differences in inpatient service by location. Increasing numbers of chronic conditions (1 and 2+ compared to none) were associated with both outpatient (AORs 2.59 and 2.78) and inpatient (AORs 1.97 and 3.01) service use.

Conclusions

This study highlights the needs to address disparities in outpatient service use for rural and urban ger populations. Compared with other WHO-SAGE countries, older Mongolians have relatively higher use of inpatient health care services. With a high prevalence of hypertension and an ageing population, efforts to achieve UHC would benefit from reorienting care services towards prevention and primary care management of NCDs to reduce the costs from hospital-based care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07156-y.

Can a Multi-Component Intervention Improve Pediatric Service Delivery in Guangzhou?

Background: Accessible, equitable, and efficient pediatric service is critical to achieve optimal child health. This study aimed to evaluate the effectiveness of a multi-component intervention on the pediatric health system over two different periods in Guangzhou. Methods: Based on the World Health Organization (WHO) "six building blocks" model and Donabedian's "Structure-Process-Outcomes" framework, an intervention package was developed to increase financial and human resouce investment to strengthen basic health care and strive for a better quality of pediatric care. This multi-component intervention package was conducted in Guangzhou to improve the pediatric service delivery during two stages (2011-2014 and 2016-2019). The main outcome indicators were the changes in the allocation of pediatricians and pediatric beds, pediatric service efficiency, and the impact of pediatricians on child mortality. Results: We found that pediatricians per 1,000 children (PPTC) and pediatric beds per 1,000 children (PBPTC) increased from 1.07 and 2.37 in 2010 to 1.37 and 2.39 in 2014, then to 1.47 and 2.93 in 2019, respectively. Infant mortality rate (IMR) and under-5 mortality rate (U5MR) dropped from 5.46‰ and 4.04‰ in 2010 to 4.35‰ and 3.30‰ in 2014 then to 3.26‰ and 2.37‰ in 2019. The Gini coefficients of PPTC and PBPTC decreased from 0.48 and 0.38 in 2010, to 0.35 and 0.28 in 2014, then to 0.35 and 0.22 in 2019, respectively, representing the improvement of pediatric resources distribution according to service population. However, equalities in the spatial distribution were not improved much. The average efficiency of pediatric service fluctuated from 2010 to 2019. A unit increase in PPTC was associated with an 11% reduction in IMR and a 16% reduction in U5MR. Conclusions: Findings suggest this multi-component intervention strategy is effective, particularly on the reduction of child mortality. In future, more rigorous and multi-faceted indicators should be integrated in a comprehensive evaluation of the intervention.

Inequality indices to monitor geographic differences in incidence, mortality and fatality rates over time during the COVID-19 pandemic

BACKGROUND

It is of interest to explore the variability in how the COVID-19 pandemic evolved geographically during the first twelve months. To this end, we apply inequality indices over regions to incidences, infection related mortality, and infection fatality rates. If avoiding of inequality in health is an important political goal, a metric must be implemented to track geographical inequality over time.

METHODS

The relative and absolute Gini index as well as the Theil index are used to quantify inequality. Data are taken from international data bases. Absolute counts are transformed to rates adjusted for population size.

RESULTS

Comparing continents, the absolute Gini index shows an unfavorable development in four continents since February 2020. In contrast, the relative Gini as well as the Theil index support the interpretation of less inequality between European countries compared to other continents. Infection fatality rates within the EU as well as within the U.S. express comparable improvement towards more equality (as measured by both Gini indices).

CONCLUSIONS

The use of inequality indices to monitor changes in geographic inequality over time for key health indicators is a valuable tool to inform public health policies. The absolute and relative Gini index behave complementary and should be reported simultaneously in order to gain a meta-perspective on very complex dynamics.

Effect of More Doctors (Mais Médicos) Program on geographic distribution of primary care physicians

This study assesses the effect of More Doctors Program (Programa Mais Médicos - PMM) on the equality in the distribution of primary care physicians (PCPs) in Brazil. Spatial data analysis, Lorenz curve and Gini coefficient were used to evaluate the geographic distribution of PCPs before and after the implementation of PMM (2012 and 2016). Data from 5,564 municipalities were used in the analyses. The results indicate that the distribution of PCPs has become more equal after PMM implementation. Between 2012 and 2016, overall Gini coefficient decreased by 11% from 0.255 to 0.227. At the state level, a statistically significant trend towards a more equal distribution of PCPs was found in 21 out of 26 Brazilian states. However, there still remains a substantial difference in the level of equality in PCP distribution, especially across states, with Gini coefficient ranging from 0.093 to 0.341 in 2016.

Distribution of midwives in Mongolia: A secondary data analysis

INTRODUCTION

Midwives are at the core of strengthening the health system, especially in the crucial period around pregnancy, childbirth, and the early weeks of life. In 2016, the national-level maternal mortality ratio in Mongolia was 48.6 deaths per 100,000 live births, but this was much higher (up to 212.9 deaths/100,000) in some rural provinces of the country. The wide variation in maternal mortality between urban and rural areas of Mongolia might be related to the distribution of midwives and equity of access to maternity care.

OBJECTIVES

In the present study, we aimed to determine the distribution of midwives in each province of Mongolia and to examine inequality in the distribution of midwives nationwide.

DESIGN

A secondary data analysis.

METHODS

Data from the Centre of Health Development and the National Statistical Office of Mongolia were obtained and analysed. First, we assessed the distribution of midwives at provincial and regional levels, along with the association between these distributions and the maternal mortality ratio in 2016. We then calculated the inequality of these distributions using the Gini coefficient and examined trends for the years 2010-2016. We compared results for urban, suburban, and rural provinces. Rural areas are sparsely populated and enormous in size, so it may be difficult access to basic healthcare services. It was considered important, therefore, to assess the number of midwives per 1000 km² as well as the commonly used indicator of per 10,000 population.

RESULTS

When the land area in each province was taken into consideration rather than only the population, wider variations between urban, suburban, and rural provinces became apparent. Provinces varied according to the number of midwives per 10,000 population by a factor of three (range 2.0-6.2/midwives); while provinces varied according to the number of midwives per 1000 km² by a factor of approximately 300 (range 0.2-61.2/midwives). The Gini coefficient for the number of midwives per 10,000 population in 2016, R = 0.201, revealed "relative" equality. This was slightly reduced from R = 0.305 in 2010 and indicated a shift toward equality. However, the Gini coefficient for the number of midwives per 1000 km² area indicated "severe" inequality of R = 0.524 in 2016. This was increased from R = 0.466 in 2010, indicating that no improvement has been seen over these years.

CONCLUSIONS

Our study suggests that two different measures of midwifery distribution should be used as indicators: number of midwives "per 10,000 population" and "per 1000 km² area". In rural areas such as parts of Mongolia, geographical features and population density are important features of the local context. To deliver healthcare services in a timely manner and within a reasonable distance for pregnant women who need care, the indicator of per 1000 km² area would be more suitable for rural and sparsely populated areas than the indicator of per 10,000 population, which is commonly used for urban and settled areas. Based on our findings, to reduce the wide gap in MMR between rural and urban areas, we recommend at least one midwife per 1000 km² area in rural regions of Mongolia.

Inequality in the Distribution of Healthcare Human Resources in Poland

Human resources are the major input in health systems. Therefore, their equitable distribution remains critical in making progress towards the goal of sustainable development. The purpose of this study is to evaluate equity in the distribution of healthcare human resources across regions of Poland from 2010 to 2017. This research by applying specifically to Polish conditions will allow the existing gap in the literature to be closed. Data were derived from the Database of Statistics Poland, and the Lorenz Curve/Gini coefficient was engaged as well as the Theil index to measure the extent and drivers of inequality in the distribution of healthcare human resources in macro-regions. Population size along with crude death rates are employed as proxies for healthcare need/demand. This research has several major findings. Mainly, it was found, that the geographical distribution of all types of human resources is less equitable than is the case with population distribution. Relatively lower equity in the access to oncologists, family doctors, and cardiologists was found. There are some noticeable differences between macro-regions in the equity level of healthcare human resources distribution. This research provides various implications for policy and practice and will allow for improved planning and more efficient use of these resources.

Comparing Regional Distribution Equity among Doctors in China before and after the 2009 Medical Reform Policy: A Data Analysis from 2002 to 2017

Background: Although China began implementing medical reforms in 2009 aimed at fair allocation of the regional distribution of doctors, little is known of their impact. This study analyzed the geographic distribution of doctors from 2002 to 2017. Methods: This study calculated the Gini coefficient and Theil index among doctors in the eastern, central, and western regions (Category 1) of China, and in urban and rural areas (Category 2). The statistical significance of fairness changes was analyzed using the Mann–Whitney U test. Results: The annual growth rates of the number of doctors for the periods from 2002 to 2009 and 2010 to 2017 were 2.38% and 4.44%. The Gini coefficients among Category 1 were lower than those in Category 2, and statistically decreased after the medical reforms (P < 0.01) but continued to increase in Category 2 (P = 0.463). In 2017, the Theil decomposition result of Category 1 was 74.33% for the between-group, and in Category 2, it was 95.22% for the within-group. Conclusions: The fairness among the regional distribution of doctors in Category 1 is now at a high level and is better than that before the reforms. While the fairness in Category 2 is worse than that before the reforms, it causes moderate inequality and is continually decreasing. Overall unfairness was found to be derived from the between-group.

Toward an optimization of rehabilitation services for persons with spinal cord injury in Mongolia: the perspective of medical doctors

PURPOSE

To explore medical doctors' views on what are barriers in providing rehabilitation services for persons with SCI in Mongolia.

METHODS

A qualitative study with semi-structured interviews was conducted with 12 medical doctors. Participants were purposely sampled. The World Health Organization (WHO)'s report International Perspectives on Spinal Cord Injury was chosen as a guide to structure the interviews. The study used inductive thematic analysis.

RESULTS

Five barriers in the provision of rehabilitation services were identified: low awareness and limited knowledge regarding SCI and rehabilitation issues, inadequate rehabilitation policies, deficiencies in infrastructure, deficiencies in equipment and medication, and a shortage of well-prepared rehabilitation workforce.

CONCLUSIONS

Based on WHO recommendations "Rehabilitation in health systems", this study provides suggestions on how to strengthen rehabilitation services in Mongolia to better respond to the needs of the SCI population. Our findings highlight that a core issue is the lack of awareness among policymakers regarding rehabilitation and its benefits at the micro, meso and macro levels of the health system. Actions are needed at the level of health policies to ensure, for instance, adequate financing and access to the services. Also, synergies between the Ministries of Education and Health can improve the training of the workforce.Implications for rehabilitationEvidence that rehabilitation services contribute to improving health outcomes and cost-effectiveness could raise awareness among Mongolian policymakers and inform their decisions on funding schemes.Health policies in Mongolia should be reformed to remove barriers in the provision of rehabilitation services for persons with complex and chronic health conditions.Rehabilitation services need to be included into the Mongolian health insurance scheme in order to improve the quality and accessibility of rehabilitation services.Synergies between the Ministry of Education and the Ministry of Health in Mongolia are needed to develop training standards for rehabilitation professionals.

Characteristics and Workload of Pediatricians in China

OBJECTIVES

Although it is widely believed that China is facing a major shortage of pediatricians, the real situation of the current national status of pediatric human resources and their working conditions has not been evaluated to date.

METHODS

We administered a survey to 54 214 hospitals from all 31 provinces in mainland China from 2015 to 2016. Hospital directors of all secondary and tertiary hospitals with pediatric services and a random sample (10%) of primary hospitals provided information on number of pediatricians and their educational levels, specialties, workloads, dropout rates, and other hospital characteristics. A data set of medical resources and socioeconomic information regarding each region (1997-2016) was constructed from the Chinese National Statistics Bureau. The Gini coefficient was used to describe the geographical distributions of pediatricians and hospitals.

RESULTS

There were 135 524 pediatricians in China or ∼4 pediatricians per 10 000 children. Pediatricians' average educational level was low, with ∼32% having only 3 years of junior college training after high school. The distribution of pediatricians was extremely skewed (Gini coefficient 0.61), and the imbalance of highly educated pediatricians was even more skewed (Gini coefficient 0.68). The dropout rate of pediatricians was 12.6%. Despite an increase in the Chinese government's financial investment in health over the last decade, physicians have been burdened with a greater workload.

CONCLUSIONS

Uneven development of the pediatric care system, inadequately trained pediatricians, low job satisfaction, and unmet demand for pediatric care are the major challenges facing China's pediatric health care system.

Inequalities in healthcare resources and outcomes threatening sustainable health development in Ethiopia: panel data analysis

OBJECTIVE

To measure inequalities in the distributions of selected healthcare resources and outcomes in Ethiopia from 2000 to 2015.

DESIGN

A panel data analysis was performed to measure inequalities in distribution of healthcare workforce, infrastructure, outcomes and finance, using secondary data.

SETTING

The study was conducted across 11 regions in Ethiopia.

PARTICIPANTS

Regional population and selected healthcare workforce.

OUTCOMES MEASURED

Aggregate Theil and Gini indices, changes in inequalities and elasticity of healthcare resources.

RESULTS

Despite marked inequality reductions over a 16 year period, the Theil and Gini indices for the healthcare resources distributions remained high. Among the healthcare workforce distributions, the Gini index (GI) was lowest for nurses plus midwives (GI=0.428, 95% CI 0.393 to 0.463) and highest for specialist doctors (SPDs) (GI=0.704, 95% CI 0.652 to 0.756). Inter-region inequality was the highest for SPDs (95.0%) and the lowest for health officers (53.8%). The GIs for hospital beds, hospitals and health centres (HCs) were 0.592(95% CI 0.563 to 0.621), 0.460(95% CI 0.404 to 0.517) and 0.409(95% CI 0.380 to 0.439), respectively. The interaction term was highest for HC distributions (47.7%). Outpatient department visit per capita (GI=0.349, 95% CI 0.321 to 0.377) and fully immunised children (GI=0.307, 95% CI 0.269 to 0.345) showed inequalities; inequality in the under 5 years of age mortality rate increased overtime (P=0.048). Overall, GI for government health expenditure (GHE) was 0.596(95% CI 0.544 to 0.648), and the estimated relative GHE share of the healthcare workforce and infrastructure distributions were 46.5% and 53.5%, respectively. The marginal changes in the healthcare resources distributions were towards the advantaged populations.

CONCLUSION

This study revealed high inequalities in healthcare resources in favour of the advantaged populations which can hinder equal access to healthcare and the achievements of healthcare outcomes. The government should strengthen monitoring mechanisms to address inequalities based on the national healthcare standards.

Mongolian Health Sector Strategic Master Plan (2006-2015): A foundation for achieving universal health coverage

Nearly half of the countries in the world are in the process of reforming and strengthening their health care systems. More recently, even low-income and middle-income countries such as Mongolia have focused increasing attention on achieving universal health coverage (UHC). At this critical point, it is necessary to track recent progress and adjust health care strategies and planning. Therefore, this study analyzed changes in the health sector toward achieving UHC based on relevant literature, government documents, and framework analysis. We also investigated how basic principles of UHC were incorporated and reflected in Mongolia's Health Sector Strategic Master Plan. This study clarified the achievements of and challenges facing the health sector that remain or emerged during the plan's implementation over the last decade. Furthermore, all of the reviewed Master Plan strategies were underpinned by basic principles of UHC. However, strategies set out in the next Master Plan will require adjustments and innovative measures to respond to current challenges. This study may be used as a reference for other developing countries to track UHC achievements and serve as a guide to establishing a nation-wide strategic plan.

Inequidad en mortalidad infantil y servicios pediátricos en Bogotá: nuevo modelo de análisis para América Latina

Objetivos Describir la relación entre la disponibilidad de servicios de salud y la mortalidad infantil en Bogotá.Métodos Se tomaron los datos de tasa mortalidad infantil (TMI) y razón de camas de hospitalización pediatricas (RCAM) y centros de servicios urgencias por localidad (RSUP) para los años 2010-2016, se estimo un GINI de distribución y un coeficiente de correlación de Pearson (r) entre las variables.Resultados Durante el periodo de años 2010 a 2016 hubo 726 946 nacidos vivos (NV) y fallecieron   7 681 niños menores de 1 año, con un aseguramiento del 94,7% de los cuales el 75% pertenecen al regimen contributivo. La tasa de mortalidad infantil disminuyó siendo 9,11 en el año 2016, pero aumentó en las localidades Tunjuelito, Antonio Nariño y Ciudad Bolivar siendo >12 por mil NV.Conclusiones Los servicios de salud tienen una distribución inetquitativa con un GINI de 0,44 para PSUP y de 0,701 para RCAM. Existe una correlación con mortalidad infantil en las localidades con menor RSUP tiene un r(-0,340) y para PCAM un r(-0,648) en el año 2016.