Differences in regional distribution and inequality in health-resource allocation on institutions, beds, and workforce: A longitudinal study in Shanghai, China

Background: The distribution of health-care resources is a critical component of health-care access, and equity is a basic principle of health-resource allocation, and foundational to achieving fairness in the provision of health services. China and its local Shanghai’s government has implemented measures to allocate health-care resources with the equity as one of the major goals since 2009.The aim of this study was to analyze differences in regional distribution and inequality in health-resource allocation on institutions, beds, and workforce in Shanghai over 7 years. Methods: A longitudinal survey using 2010–2016 data, which were collected for analysis. The study was conducted health-resource allocation on institutions, beds, and workforce in Shanghai, China. Five health-resource indicators were used to measure health-resource distribution at the city and district levels. Furthermore, the Theil index was calculated to measure inequality of health-resource allocation. Results: All quantities of health-care resources per 1000 people increased across Shanghai districts from 2010 to 2016. Compared with suburban districts, the central districts had higher ratios on five health-care resource indicators, and faster average growth in the bed and nurse indicator, and slower growth in the institution, technician and doctor indicator. The Theil indices of the technicians, doctors, nurses and beds had higher values than that of institutions every year from 2010 to 2016; furthermore, the Theil indices of the indicators, except for doctors in hospitals, all exhibited downward time trends. Conclusions : Increased health-care resources and reduced inequality of health-resource allocation in Shanghai during the 7 years indicated that the measures taken by the Shanghai government in the new round of healthcare reform in China since 2009 had been successful. Meanwhile there still existed regional difference between urban and rural areas and inequality between institution and workforce, especially doctors.


Background
Reasonable health-resource allocation is essential to achieving health service equity, which contributes to public health outcomes and mitigates social conflict [1][2][3]. In many countries, healthcare reform aims to provide universal and equitable access to health care, which is recognized as a fundamental human right. The distribution of health-care resources is a critical component of health-care access. Furthermore, equity is a basic principle of health-resource allocation, and it is foundational to achieving fairness in the provision of health services. Many studies have demonstrated that highly accessible health care can play a crucial role in promoting regional health equity. The equitable allocation of health-care resources helps deliver health-care resources to those most in need and ensures accessibility to basic health services as well as fairness for vulnerable populations [4]. Moreover, inequality in health-care resources has adverse consequences, such as the uneven distribution of health-care allocation, which in turn leads to growing inequalities between the rich and poor with respect to health and the economic burden of disease [5]. In 2009, China launched a new round of healthcare reform with the aim of providing households with secure, efficient, convenient, equitable, and affordable health-care services by reversing the market-oriented health system into one with universal benefits. The reform strengthened the government's role in healthcare, its commitment to equity, and its willingness to experiment with regulated market approaches. Besides genetic characteristics, the Chinese healthcare system also has some more special features. Take the health financing system as an example, it collects revenues from three main sources: government expenditure, social expenditure and out-of-pocket (OOP) payments in the domestic classification. The revenues are distributed through the basic medical security system consisting of Basic Medical Insurance (BMI) schemes and Medical Financial Assistance (MFA) schemes for the poor to cover urban and rural residents in China. Under BMI, more specifically, employees in urban areas are covered by Urban Employee Basic Medical Insurance (UEBMI), unemployed residents in urban areas are covered by Urban Residents Basic Medical Insurance (URBMI) and residents in rural areas are covered by New Rural Cooperative Medical System (NRCMS). The MFA is the security net for the poor in both urban and rural areas, which helps them to enroll in basic medical insurance and also provides extra reimbursement for medical expenses. The public health system, which is mainly financed by the government, provides basic public health services to all residents free of charge. Accordingly, since 2009, the Shanghai government has implemented corresponding measures to allocate health-care resources between central districts and rural ones, conforming tightly to the national health reform strategies and guidelines and three tenets for Shanghai's healthcare reform (build a foundation, manage for the long term, and make reforms sustainable). For example, in 2009, shanghai government spent approximately $1 billion to carry out a policy named "5+3+1" to strengthen the role of public hospitals, and to deepen health-care reforms. Under the policy, nine tertiary hospitals in rural areas were constructed and a "1560" accessible radius to health care were formulated, so that patients in urban areas can walk to a nearest medical institution within 15 minutes, and patients in suburban districts can visit a tertiary hospital within 60 minutes by public transportation [6]. As a result of these measures, nine new tertiary hospitals were built and 6000 beds were provided in the outer rings of Shanghai. Rural patients no longer had to drive an hour or two to visit tertiary hospitals in the city center. With the increase number of institutions, beds and workforce transferring from "mother hospitals" to new hospitals, the distribution of health-care resources has become more balanced [7,8]. However, many studies examined variations in the quantity and inequality in health-resource allocation in China have noted widening urban-rural disparities in health-care resources across China [9][10][11][12][13][14], including the one conducted in Shanghai [15]. However, they have overlooked the difference over time in health-resource allocation as well as its association with China's 2009 healthcare reform. Considering the overall goal of China's new health-care guidelines and plans to promote more equitable and efficient health-care resource distribution, it is essential to study the differences in health-resource distribution and the inequity of allocation in Shanghai over time since the 2009 reform. Therefore, the purpose of this study was first, to investigate regional difference in healthresource distribution and second, to describe the inequity of their allocation over 7 years

Patient and public involvement
This study used secondary data from Yearbooks (2010-2016) in Shanghai of China and did not require patient or public involvement.

Data analysis
The annual growth rates (AGRs) of the five types of healthcare resource were also calculated from 2010 to 2016. The formula of AGR is as follows: where B is the quantity of the five types of healthcare resource in 2016, A is the quantity of the five types of healthcare resource in 2010, and n represents the number of years. We used AGR (Average Growth Rate) instead of GR (Growth Rate) to measure the time trends of healthcare resources for the advantages of its accuracy to calculate historical tracks and comparability of the relative performance of the health-care resource allocation.
Many measures exist for evaluating the equity of health-resource allocation, such as the Lorenz curve, Gini coefficient, and Theil index. The Theil index is a statistic primarily used to measure income inequality or other economic phenomena among different individuals or within varied groups. It is a special case of the generalized entropy index and one of the most widely used measures of inequality in regional economic development. The Theil index was proposed by econometrician Henri Theil at Erasmus University Rotterdam [16], and it can be formulated as follows: , where is the Theil index, which represents income allocation inequality, and and is the income of individual i and the average income of the population, respectively. The Theil index has another form to measure the inequality between different groups, which is known as the between-region difference. This formula can be written as follows: College Station, TX, U.S.) [17], and maps were generated using ArcGis 10.6 (Environmental Systems Research Institute, Redlands, CA, USA) [18].

Results
Differences in regional distribution of health-resource allocation at city and district levels in Shanghai from 2010 to 2016 Table 2 presents descriptive statistics of indicators of health-resource allocation in Shanghai.  (Table 3).         present a collaborative hierarchical medical system that meets people's health-care demands [19][20][21][22]. This included not only perfecting plans for the geographical distribution of health-care resources across different regions and districts [23], but also maintaining a dynamic balance in allocation between facility and workforce. On the demand-side, the government has educated Chinese people about the "big health" concept to foster healthy lifestyles, as well as re-designed medical insurance to widen coverage among poorer people [24], under which an increasing number of patients were given reasonable access to health-care resources. Thus, the aforementioned measures of the Chinese and Shanghai governments have resulted in increased numbers of institutions, beds, technicians, doctors, and nurses across varied districts, and also reduced the inequality in health-resource allocation from 2010 to 2016. Numerous studies have reached similar results [25][26][27][28].
Secondly, this study observed regional differences in health-resource distribution at district level from 2010 to 2016. Health programs were unbalanced in their development when central and suburban districts were compared, which resulted in urban-rural regional disparity in healthcare resources. This was due to some historical reasons as followed. Most of public hospitals, especially tertiary hospitals were originally distributed in urban or municipal districts. They received more supports including fiscal reimbursement and policy inclination from Shanghai government than those located in rural districts. Furthermore, due to the new 2009 reform initiatives to strengthen the status of public hospital, plus the improved transportation convenience and accessibility to health care, the institutions located in urban districts were overwhelmed in term of beds, equipment and other facilities, forming a Matthew Effect that, the institutions in urban districts were visited by more and more people, while they were more financially invested by the government. Contrastedly, the institutions in rural areas were underdeveloped to form the socio-economic and health-care accessibility gaps between urban and suburban districts. Some relevant studies have also noted the distribution imbalance of institutions [26,27,29,30]. Furthermore, this effect also led to increasing numbers of the health workforce being attracted from suburban to central districts for pursuing higher salary, prospective career development in urban hospitals. We also found that some suburban districts grew faster than urban ones did in the numbers of institution, technician and doctor in light of AGRs. This was possibly attributed to some measures taken by Shanghai government to implement the strategy of "5+3+1" since 2009, which aimed to multiple the numbers of the tertiary hospitals and their workforce, equipment and other facilities in rural districts, in order to narrow the public hospital distribution gap between the urban and suburban districts and increase health care accessibility for residents of rural districts. For example, Chongming, Fengxian, and QingPu district were referred to the "3" sub-strategy targets of "5+3+1" public hospital reform to update their public hospitals into tertiary hospitals to meet the demands of health-care in these three administrative divisions since 2009. This result on the regional difference is similar to those of studies that discovered an overcentralized health-care resource in urban areas and rapidly growing numbers of institution and workforce items in suburban areas in China [31][32][33][34].
Third, this study used the Theil index to analyze inequality in health-resource allocation. The index has some disadvantages, such as being complex to calculate and interpret; a wide variety when distribution varies regardless of the change that occurs in the top, middle, or bottom tier of resources; and the fact that when comparing populations with different sizes, the calculation is dependent on the number of individuals in the population or group. Nonetheless, this measurement method can still be robust when determining inequality within and between group components, with high sensitivity to the efficiency of health-resource allocation. This is because the index is decomposable by groups, can incorporate group-level data, and is particularly effective at paring effects in hierarchical data sets [35]. This finding was similar to those of some relevant studies, which have confirmed the physician distribution gap among different regions or hospitals of various sizes [43][44][45][46].
The present study has several limitations. Firstly, the data used could potentially only reflect the health-resource allocation status in Shanghai at the cut-off because we could only obtain them from the Chinese Yearbooks, which are usually published officially at least 2 years after the year the data were collected. Therefore, crucial information could have been omitted from our data. In the future, a new study on changes in health-resource allocation from 2017 to the present, along with comparisons with the present study, can be conducted when the data are available. Secondly, this study did not consider the effect of the population's health outcomes on health-resource allocation. According to the health capacity paradigm theory [47], the population's health status in a region will have mutual effects on health-resource allocation in that area. Due to time and resource constraints, we did not consider these factors, which may have somehow affected the results. Thirdly, we selected indicators for health-resource allocation rather than indicators of the quality of health services. Factors represented by other unmeasured indicators may have influenced the results. Thus, integrating the indicators of health-resource allocation used in this study with those of health service quality may yield more robust results in a future study.

Conclusion
Health accessibility for residents there were needed to be strengthened further. Therefore, to achieve a regional balance in health-care resource distribution between central and rural areas and improve the equality of workforce allocation in Shanghai, policies should not pay attention to improve the socioeconomic levels in rural districts by raising income, make transportation conditions better, invest more fiscal funds and providing more access to health-care service for residents of rural districts. They should also focus on the balance of physician distribution between institutions at various levels, such as remobilization, job performance evaluation. To more deeply explore health-resource allocation, future studies will be conducted to integrate the indicators used in the present study with indicators of health service quality.

Abbreviations
AGR：Annual Growth Rate.