There are several challenges impede the development of public health system in Beijing, such as the pressure from demographic changes3, changes in the spectrum of diseases and environmental factors4 as well as the impact of public institutional reforms3,5. Besides these outside challenges, we acquired three major inner problems for the public health system development in Beijing.
3.1 Lack of top-level design, and lack of co-ordination
The public health as a baseline responsibility for public safety in Beijing still falls short of the ideal. Government leaders at all levels have not yet come to a shared understanding of the connotation and importance of public health, and there are differences in their understanding of the concept of "big hygiene, big health", especially among district governments. There is also a lack of evaluation of the government's public health work effectiveness.
Most public health institutions work in isolation from each other, and the related assessment and evaluation have not been given "top priority". Professional institutions are highly organized and territorial, while the medical and prevention health systems have been divided for a long time, and the person-oriented whole-of-life cycle health management service has not been realized. The current public health work has failed to adapt to the changes in the spectrum of diseases, and the prevention and control of chronic diseases lacks a clear focus. Job descriptions are unclear and efficiency is low. The allocation of responsibility of public health functions of medical institutions in chronic disease management and health promotion is still unclear, and the conferment of authority and the assessment of work still lack a rational basis.
3.2 Inadequate government investment
The total amount, structure and mode of government investment in public health do not meet the needs for the development of the system. There are three important reasons.
First, government spending on public health is low. Although Beijing municipal governments at all levels have increased the investment in public health, the government's financial guarantee is still insufficient in terms of its status as the capital, and its goal of building a world-class, harmonious and livable city. The medical and health expenditure in the city's total fiscal expenditure is relatively low. Compared with education expenditure, the city's fiscal expenditure on education is basically 2.3 ~ 2.5 times the medical and health expenditure, and the proportion of expenditure on education in the city's budget is 9 ~ 10 percentage points higher than that of medical and health6. In addition, funding of public health institutions makes up a relatively low proportion of the overall funding of medical and health institutions. Government funding for medical and health institutions has been increasing, but the proportion for medical institutions has always remained in absolute dominance (about 82%), and public health institutions (including specialized public health institutions, nursing homes and medical professional scientific research institutions and other institutions, including the main public health agencies) receive only 18% with no growth in funding7. The investment in system construction (software and hardware) for public health is also still low. At present, the government’s funding for public health mostly concentrates on the basic public health service and major public health projects, while there is insufficient investment in the software and hardware development to promote the development of the system.
Second, the dynamic adjustment of financial investment guarantees mechanism has not been established, which creates difficulties in meeting the current development needs of disease prevention. During the 12th Five-Year Plan period, the average annual growth rate of financial allocations to professional public health institutions in Beijing was only 3.67%, which was lower than the growth rate of Beijing's GDP (9.09%) and the growth rate of funding for medical and health institutions in Beijing (14.01%), which restricted the financing channels for the development of the public health system.
Third, the municipal government only funds the day-to day coast of public health program. It focuses on routine operations but does not consider investing in special projects or new major health research. At the same time, public health investment focuses more on hard infrastructure (buildings, standard equipment), and insufficient attention is paid to “soft” development such as staff development or skill updating.
Fourth, the public health investment in each region is not balanced, and some districts and counties are comparatively underfunded. According to the results of “the 2017 comprehensive evaluation report on Beijing's health development”, the per capita government health expenditure and per capita health human resources in Fengtai, Daxing and Changping districts are significantly lower than those in other districts and counties.
3.3 Challenges to the stability and development of public health staff
There is a high turnover of professional and administrative staff in the public health institutions. First reason is there is no rational planning for promotion, and the staff recruitment policy is not attractive. The city's professional public health institutions are funded by the development project for high-level technical personnel team of Beijing health system, with only 13 person, including 2 academic leaders (Municipal Center for Disease Control and Prevention ) and 11 academic core staff, a far lower percentage than the medical institutions. On the other hand, with the shift of emphasis of public health from prevention and control of infectious diseases to prevention and control of chronic diseases and response to public health emergencies, there is a lack of inter-disciplinary staff who have both professional and management skills, and the leadership of public health talents needs to be further improved. In addition, there is a shortage of basic level staff. Recruiting new staff is difficult, especially for the areas of women and children’s health, mental health and health. The promotion and assessment mechanism of public health related institutions and personnel do not motivate institutions and personnel to perform their public health functions.
Second, the reform of public organization funding has had a great impact on the stability of the whole public health system. The income level of the personnel of public health institutions has been generally lower after the reform. The average salary of the Beijing CDC, the Health and Family Planning Supervision Institute and the Prevention and Control Institute is generally 20–60% lower than the average wage level of the rest of Beijing's health staff, Moreover, there is a gap of nearly 40% between the salary level of public health personnel in first-tier cities, such as Shanghai, Guangdong and Shenzhen, and Beijing, resulting in a serious problem in attracting new staff. At the same time, there are serious staff losses, and the vacancy rate in some institutions such as mental health is high. Grassroots public health workers have a heavy workload and great pressure, but their sense of occupational achievement and material incentives cannot be matched reasonably. As a result, the stability of the grassroots public health team is affected.
Third, there is a lack of analysis and definition of the functions and categories of public health activities under the concept of the slogan "great hygiene and great health". The scientific research responsibility of different levels and functions of public health institutions is still unclear, and the development of priorities and key disciplines is weak.
3.4 Lack of overall planning for a public health information system
The health information management system is inadequate. There is little integration of IT professionals into the public health system. Information security is also inadequate.
First of all, existing information systems are mostly built around specific fields and scopes, which are relatively closed systems. They lack public health information platforms that can facilitate connectivity, information sharing, unified standards, and convenience and efficiency. Thus the current systems cannot meet the needs of a human-oriented health management information service for the population. It is necessary to further improve the overall planning and integrated utilization of information resources.
Second, the investment in public health informatization is insufficient, and health informatization manpower is also insufficient. Compared with the current needs, the informatization development has not been clearly included in the scope of capital investment policy. At the same time, there is a shortage of interdisciplinary health informatization workers with multiple backgrounds in medicine, public health and informatics, and the recruitment policy is relatively weak.
Third, the balance between information security and information disclosure has not been clearly thought out. Information security and supervision still face challenges. On the other hand, privacy protection is weak. Personal data is too easily available to unauthorized persons. And the information that should be publically available is too often kept secret. There is no system for deciding what data is confidential and what should be public.