This research performed a comparative spatio-temporal analysis of health workforce (HT, LD, RN, pharmacist, technologist, and intern) in the Sichuan province of China, which produced much evidence for formulating and promulgating policies and adopting strategies of human resources attraction and retention based on time and space. We would like to explore the spatio-temporal analysis of different health workforce and then lay special stress on discussing future strategic planning and policy development.
In general, China is always conforming severe problems such as scarcity of qualified HT [43, 44], uneven distribution of health workforce , so is Sichuan. There were several reasons explaining the situation like the unbalanced development among regions, such as the tension between doctors and patients [46, 47], the huge economic and social difference between regions. The research displayed the problems in a systematic way and manage to find effective methods to tackle it. On the whole, the global Moran's I of the number per 1000 population of health workforce in Sichuan all reached the 0.001 significance level in the whole research period, demonstrating the spatial agglomeration among all the health human resources, which strengthened our argument about issue of misdistribution and supported part previous studies. Obviously, the spatio-temporal characteristics of HT, LD, RN, pharmacist, technologist, and intern in Sichuan remained different in trends, hotspots, clusters and changing patterns.
On the one hand, the HT contained the other health workforce in our analysis. We would like taking a look at it first. The absolute number increased from 303051 to 530306 in nine years, the average annual growth rate is 7.24%, which also could be acquired by the temporal analysis. According to the previous analysis, the average annual growth rate of China is 6.25% during the research period, while the number is 5.43%, 6.20% and 7.24% respectively in Beijing (Eastern China), Hubei (Middle China) and Ningxia (Western China). By the end of 2018, the number of HT in Sichuan province accounted for only 5.90% of the total number of HT in China. Zhang found the number per 1000 population of the different health workforce is increasing year by year , the same results were discovered by Xiao and He [49, 50]. When it comes to spatial analysis, on the one hand, to our surprise, the citizens tend to believe there is lack of health human resources in Qinghai Tibet Plateau, however, according to our study, the HT is probably the thing that Sichuan has least in Tsinling Mountains, Yunnan-Guizhou Plateau, Hengduan Mountains and the transition zone of mountains and basins. The LL cluster and the most like cluster areas echoed and supported the result. In contrast, the analysis of the number of per square kilometres told difference. The distribution of HT is strictly negatively correlated with areas. Qinghai Tibet Plateau is confronted with a scarcity of HT. On the other hand, the resource-rich areas were the capital Chengdu and the city of iron and steel Panzhihua. The HH cluster and most likely cluster area demonstrated our findings. The economic state, population, geomorphological type and area of units were important determinants of shortage and uneven distribution of health workforce. In recent years, Chengdu and Panzhihua depended on a high salary, career development and quality of life to attract and retain HT. At the same time, the special minority policies in China tend to encourage health workforce to stay in minority area such as Qinghai Tibet Plateau, while from the perspective of population and area of units, the eastern areas had a relatively large population and small areas, which all the special circumstances were going unnoticed.
On the other hand, LD and RN were the core of HT, which would be analyzed separately. The absolute number of LD went up from 97070 to 126634 with an average annual growth rate of 3.38% from 2009 to 2017, while the number is 6.78%, 5.60% and 5.36% in Beijing, Hubei, and Ningxia. As to RN, the absolute number increased from 55532 to 143314 with an average annual growth rate of 12.58%, which number is 9.04%, 9.84%, and 10.30%. The number per 1000 population of LD and RN was 2.34 and 2.77. According to data of the World Bank WDI Database in 2018, the physicians per 1000 population in high-income countries is 3.0 [51, 52]. Sichuan still needed to take various measures in attracting doctors. Sichuan province did a relatively satisficed job in attracting and retaining nurses. The overall construction of nursing human resources in Sichuan Province had been improved, but the ratio of doctors and nurses was far short of what is required of 1:2 in the trial draft of organization budgeting principles on Comprehensive Hospital personnel issued by the National Health Commission of the PRC . As to spatial analysis, the shortage of LD and RN was exposed to western and eastern areas. Our research is comparative, so compared with the rich place, the plateau and mountain areas were still lack resources. Furthermore, except for sufficient resources in capital and rich place, some core areas of poor territories exhibited adequate resources, as shown in LL and HH cluster map. As to the RN, Cao applied the Gini coefficient and Thiel index to assess the equity of Sichuan, discovering the number per 1000 population of RN in Chengdu, Panzhihua, Zigong, Luzhou and Yaan was higher than average level of Sichuan, which was similar with our results . The uneven distribution was discovered in two levels, the capital and rich snatched resources from other areas, while the core area in poor place attracted health workforce from other places, which is in accordance with the law of development.
Furthermore, pharmacist and technologist were important parts of health workforce. According to our analysis, the temporal trend remained constant upward. The spatial distribution is similar with another health workforce with the HH cluster in Chengdu and Panzhihua, while LL clusters were found in eastern areas. The related research was quite rare. Li conducted research about the pharmacist in China, discovering Zhejiang, Jiangsu, Guangdong, Shandong, and Shanghai are the top five provinces in the number of pharmacist in China . The above five provinces are in the eastern region, accounting for 38% of the total number of pharmacist in China. The number of pharmacist is relatively deficient in Xizang, Qinghai, Ningxia, Heilongjiang, and Hainan. Sichuan is in the middle . Nowadays, China had an ample number of pharmacist. From 2009 to 2017, the number of pharmacist has increased year by year. However, due to the backward legislation of pharmacist and lacking a clear system for the allocation and use of pharmacist, the curve of the number of pharmacist in China is rising slowly. According to some interviews we conducted in the village, the technologist was rare in some places, which led to no professional and qualified technologist to use the medical equipment.
Interestingly, interns displayed quiet unique characteristics comparing with others. The absolute number of interns went up from 28614 to 41050 with an average annual growth rate of 4.61% from 2009 to 2017. However, the spatial distribution was totally different from another health workforce. The Qinghai Tibet Plateau and capital had the highest number per 1000 population, as shown in the hierarchical map and cluster map. In order to improve the health human workforce in poor areas, the Chinese government required interns to work in relatively remote and poor territories before becoming a practicing physician. The policy had a limited effect in dealing with the misdistribution in health workforce.
To conclude, four main findings should be pay attention to: the whole health workforce of Sichuan province had an upward trend. Comparing with other province, the growth rate was relatively high; the areas with the scarcest resources were eastern places, including Tsinling Mountains, Yunnan-Guizhou Plateau, Hengduan Mountains and the transition zone of mountains and basins; misdistribution of health workforce had two levels, among the province and cities; the Qinghai Tibet Plateau has enough interns, while being short of other HT.
As to the limitation of the research, this study displayed simplification of indicator. More indicators should be include; the spatial analysis reflected the comparative results, so the classification of hierarchical and cluster maps only displayed relative situation of health workforce; only the case of Sichuan is not enough to extend to the whole country, other units should take specific economic and social conditions into account when formulating corresponding policies.