This study analyses the equity of distribution in western China from 2014-2018, supplemented the analysis of health resource allocation in western China and provides reference for policy makers in the Chinese government.
On the basis of the analysis, we found that firstly, the overall health resources showed an increasing trend, however, the total health resources must be further improved. From 2014 to 2018 in western China, every 1000 people were allocated medical (assistant) practitioners, registered nurses, and number of beds which showed a trend of steady growth, indicating that Chinese government obtained some achievements in increasing health resources in western China, and residents’ medical needs had been better meet. which is consistent with the research results of Ma Lu et al. [38]. However, according to ‘China 13th Five-Year Health and wellness Plan’, there should be six beds in medical institutions, 2.5 medical (assistant) practitioners and 3.14 registered nurses ever per 1,000 people [39]. As can be seen from Table 1 and table 2, in 2018, except for Guangxi and Tibet, the number of medical beds for every per 1,000 people basically reached the expectation of the plan. However, there were only 5 provinces (autonomous regions and municipalities) - Shanxi, Qinghai, Ningxia, Xinjiang and Inner Mongolia – have reached the expectation of the number of medical (assistant) practitioners for per 1,000 people in the ‘China 13th Five-Year Health and wellness Plan’. The situation of registered nurses was more serious, only Shaanxi and Ningxia provinces had over 3.16 registered nurses for every per 1,000 people, meeting expectations. It can be seen that there is still a gap between the total amount of health resources in western China and the “13th Five-Year Plan”, especially human resources. Moreover, in 2018 , there were 6 beds, 2.59 medical (assistant) practitioners and 2.94 registered nurses for every 1,000 people in the National Health Service[40].Comparing the relevant data of western China exhibited that the health resources for every 1000 people in western China were generally lower than the national average. By comparison, Zhejiang province, which located in the more developed eastern region of China, has 6.65 beds, 3.33 medical (assistant) practitioners and 3.51 registered nurses per 1,000 people in 2018[41]. Shandong province had 6 beds, 2.89 practicing (assistant) practitioners and 3.21 registered nurses per 1,000 people in 2018[42]. Hunan province, which located in central China, had 6.6 beds, 2.62 medical (assistant) practitioners and 2.67 registered nurses per 1,000 people [43]. Hubei province, which also located in central China, had 6.37 beds, 2.57 medical (assistant) physicians, and 3.23 registered nurses per 1,000 people[44]. The four representative provinces in eastern and central China is basically at or above the average level of China, The compared results shows that the total health resources in western China still must be improved. This may be related to the underdeveloped economy in western China and the tendency of government health resource allocation. The government is the main force to increase the total amount of medical resources. Therefore, the government must strengthen its functions in health resources allocation, enhance the feasibility of policies, strengthen relevant safeguard measures, and ensure the implementation of relevant policies to improve the total amount of health resources in the underdeveloped areas in western China, and further realize the goal of ‘health equity for all’ which emphasized in the ‘13th Five-Year Plan’ and the ‘Outline of healthy China 2030 Plan’[45].
Secondly, the geographical dimension of health resource allocation equity must be improved. Based on the analysis results of Lorenz curve, the curve in population dimension were nearer to the curve of absolute equality than that in the geographical dimension. Gini coefficient and Theil index were also lower in population dimension than that in geographic dimension. These results implied that the health resource allocation had more equity in the population dimension than that in the geographic dimension, and the inequity distribution of health resources in western China still shown an increased tendency. This result is basically consistent with the related studies[46,47]. The reason may be is that currently, China mainly chooses to allocation the health resources on the basis of the population density [48-50]. Hence, the distribution of health resources in the geographical dimension was more unequal also extending in other provinces and cities[51,52]. WHO recommends that everyone have access to affordable, quality health care services. However, this allocation standard can easily lead to problems such as small service radius, low service accessibility and low resource utilization, which may affect the population's easier access to health resources, and inconsistent with the GOAL of "universal health coverage" advocated by WHO. In addition, the geographical environment in western China is relatively complex, for instant, Xinxiang, Inner Mongolia, Tibet, and other provinces (autonomous regions and municipalities) geographic area is larger, high altitude, low population density, Guangxi, Guizhou, Chongqing and other provinces (autonomous regions and municipalities) are mostly mountainous, traffic inconvenience. These unique climatic and geographical conditions also affect the geographical equity of health resource allocation in western China. The equity of geographical distribution of health resources will affect the accessibility of health resources, thus affecting the health equity of residents[53]. Thus, the government must improve the accessibility of health resources through tiered medical services, medical treatment alliances, strong economic investments, Internet hospitals and other diversity methods [54-56]. Moreover, the government can also use Geographic Information System (GIS) to further improve the accessibility of health resources distribution.
Thirdly, the inequity of health resources distribution was mainly came from the intra-group. Based on the analysis of the Theil index contribution rate in the two dimensions, the intra-group contribution rate was all over 60%, higher than the inter-group. This result indicate that the inequality of resource allocation is mainly caused by the unequal distribution of health resources within the provinces (autonomous regions and municipalities) in western China. This may be caused by China’s current resource allocation policies, the different population densities in different cities can be one of the reasons. The unique geographical feature of western China which described above is further exacerbated the situation. Some western rural areas are extremely inconvenient transportation, vehicles cannot reach, have caused inconvenience to the construction and transportation health resources. Moreover, the health resources allocation is related to economic development[57], level of economic development amongst cities and counties can lead to the unequal distribution of health resources inside the provinces (autonomous regions and municipalities). Therefore, when formulating regional development plans, the government should consider the economic strength of different regions and make targeted bias policies to reduce the inequity in the human resources allocation caused by economic reason.
Fourthly, we found that human resources distributive inequality was more obvious in the intra-group in the two dimensions. In 2018, the intra-group contribution rate of human resources in the population dimension has reached over 95%. Moreover, the intra group distributive inequality of medical (assistant) physicians showed an increasing trend in population dimension. This phenomenon can be owned to the relevant policies and the characteristics of western China. From the perspective of relevant policies, the incentive systems such as salary and promotion for medical staff employed in the community medical institutions is insufficient. In addition, the attraction of relatively developed cities and large medical institutions leads to the low willingness of medical staff to work in primary medical institutions, which resulting in the differences of health resources distribution in urban and rural [58,59]. In terms of the western own characteristics, Yunnan, Tibet, and other places with high altitude, easy to hypoxia, it is difficult for staff to adapt. In addition, there are many ethnic minority areas in western China, such as Ningxia, Guangxi, Guizhou etc. These areas have their own traditional culture, and most of the primary medical institutions are located in rural areas, which are more influenced by traditional culture and have more backward economic conditions. The factors above resulting in more difficult working environment, and staff are difficult to integrate into them, and it is difficult for them to obtain a sense of identity and sense of belonging. These factors restrict the introduction of professional talents, and the inequity human resources allocation in the western provinces (autonomous regions, municipalities). Human resource is one of the key resources of health resources[60]. Hence, the government should strengthen the training of medical personnel, moreover, we suggest that the training environment should be optimised by strengthening the incentive system and broadening the promotion channels to encourage more medical personnel to work in primary medical institutions, pay attention to the humanistic care for medical staff and help them integrate into local life to further realize health equity and improve the equity of human resources allocation.
The present study holds some limitations. Based on the “China 13th Five-Year Health and wellness Plan”, the indexes of medical and health service system also include the number of general practitioners per 10,000 population and the proportion of beds in socially run hospitals in total number of hospital beds. Meanwhile, efficiency of health resource use is also a key factor affecting health equity and the capacity of health institutions to provide services[61]. However, due to the limited availability and integrity of data collection, the above problems were not further analysed in this paper.