Objectives: China has achieved certain progress in expanding the coverage of primary healthcare institutions (PHCI), promoting equitable access to essential medical and health resources, and advancing universal health coverage. However, disparities in equitable access among different regions and income groups remain substantial. This study aims to analyze regional differences in the distribution of PHCI after the new healthcare reform and to explore the main factors influencing their distribution, so as to provide references for optimizing the allocation of primary healthcare resources.
Methods: Data on the number of PHCI and factors influencing regional distribution differences from 2009 to 2022 were collected for 31 provincial-level administrative regions (hereinafter referred to as "administrative regions"). The Gini coefficient, Theil index, and the PHCI health resources density index (PHRDI) were used to evaluate the equity of PHCI distribution from 2009 to 2022 based on population, geographic area, and health level. PHRDI and each influencing factor were classified into 5 levels using the natural breaks method, and statistical maps of annual PHRDI distribution for each administrative region were drawn accordingly. Taking the number of PHCI in 2022 as the dependent variable, 15 indicators were selected as independent variables, and a geodetector was used to analyze the key factors influencing PHCI distribution.
Results: In 2022, the number of PHCI in China was 979 768, representing an increase of 11.07% compared with 2009. The distribution of PHCI in 2022 by year-end permanent resident population (Gini coefficient 0.178, Theil index 0.051) was absolutely equitable; distribution by the number of women receiving systematic maternal management (Gini coefficient 0.227, Theil index 0.084)/the number of low-birth-weight infants (Gini coefficient 0.335, Theil index 0.179) was relatively even/comparatively appropriate; distribution by geographic area (Gini coefficient 0.628, Theil index 0.701) was highly inequitable, with inter-regional and intra-regional differences contributing 58.45% and 41.55%, respectively, to the overall inequity by geographic area. Over the years, PHRDI consistently showed a gradual decline from eastern to western regions. Compared with 2009, 10 administrative regions achieved an upgrade in PHRDI level by 2022, with the largest number in the eastern region (5 administrative regions). Year-end permanent resident population, number of PHCI health personnel, number of women receiving systematic maternal management, geographic area, local health expenditure, regional GDP, and total dependency ratio were the main factors influencing regional differences in PHCI distribution (all P<0.05). The individual explanatory powers of these indicators were 75.6%, 69.3%, 68.0%, 47.3%, 44.9%, 44.0%, and 41.5%, respectively, and there were enhanced interaction effects among the influencing factors.
Conclusions: The total number of PHCI in China has increased, but the growth rate is relatively slow and human resources remain relatively insufficient. There are regional differences in PHCI distribution, with PHRDI showing a gradual decrease from east to west. The establishment of PHCI should not only consider regional population size, but also comprehensively take into account factors such as local health personnel, economic development, health level, age structure, and geographic area.
目的: 中国在提高基层医疗卫生机构(primary healthcare institutions，PHCI)覆盖面，推进基本医疗卫生资源公平可及和全民健康覆盖方面取得了一定的成绩，但不同地区、不同收入人群间的公平可及性差异仍较大。本研究旨在通过分析新医改后PHCI的区域分布差异，并探讨影响其分布的主要因素，为优化基层医疗卫生资源配置提供参考。方法: 纳入31个省级行政区(以下简称为“行政区”)2009—2022年PHCI数量及影响其区域分布差异因素的数据进行研究。采用基尼系数、泰尔指数、PHCI卫生资源密度指数(PHCI health resources density index，PHRDI)，基于人口、地理面积和健康水平评价2009—2022年PHCI分布的公平性;PHRDI及各影响因素采用自然断点法分为5个等级，并据此绘制各行政区历年的PHRDI分布统计地图;以2022年PHCI数量为因变量，选择15个指标作为自变量，运用地理探测器分析影响PHCI分布的关键因素。结果: 2022年中国PHCI数为979 768个，相对于2009年增长11.07%。2022年PHCI按年末常住人口数(基尼系数为0.178，泰尔指数为0.051)分布绝对公平，按孕产妇系统管理人数(基尼系数为0.227，泰尔指数为0.084)/低出生体重婴儿数(基尼系数为0.335，泰尔指数为0.179)分布比较平均/比较合理，按地理面积(基尼系数为0.628，泰尔指数为0.701)分布非常不公平，区域间差异、区域内差异对地理面积分布不公平的贡献率分别为58.45%、41.55%。历年PHRDI均呈现从东部至西部逐步降低的现象。与2009年相比，2022年有10个行政区实现了PHRDI等级的提升，其中东部最多(5个)。年末常住人口数、PHCI卫生人员数、孕产妇系统管理人数、地理面积、地方卫生健康支出、地区国内生产总值(gross domestic product，GDP)、总抚养比是PHCI区域分布差异的主要影响因素(均P<0.05)，各指标的单独影响解释力分别为75.6%、69.3%、68.0%、47.3%、44.9%、44.0%、41.5%，各影响因素之间存在增强交互作用。结论: 中国PHCI总量有所增长，但增速相对较缓，卫生人员相对不足。PHCI分布存在区域差异，PHRDI呈现从东部至西部逐步递减的趋势。PHCI设置不仅要考虑地区人口数，也要结合当地卫生人员数量、经济发展水平、健康水平、年龄结构、地理面积等多因素统筹规划。.
Keywords: Gini coefficient; Theil index; equity; geodetector; influencing factors; primary healthcare institutions; primary healthcare institutions health resources density index; regional distribution differences.