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There is very little information on the activities of village health providers, particularly in terms of quality of service for childhood illness management and its determinants in China. The objectives of this study were to assess the performance of village doctors in relation to the childhood illness management, and the influence of a range of factors at different levels of China's rural health system. It included a detailed description of the policy and regulatory framework governing the village health providers and the situation assessment on its implementation and enforcement in rural Sichuan. Both qualitative and quantitative data were collected in this cross-sectional study, which involved literature review, interviews, focus group discussions, a postal survey in one province, and a field survey in four selected counties. The researchers reviewed health-related regulations at national, provincial, and county levels that govern village health facilities and personnel, and investigated their implementation and enforcement by field visits to 130 village health facilities. Village health providers' tasks and interpersonal performances were defined based on IMCI standards and local practice norms, and were assessed during the same field visits, by both trained MCH doctors and simulated patients. With selected indicators as outcome variables, multivariable regression analysis was conducted to identify the determinants of both task and interpersonal performances, using simulated patient data only. Patient satisfaction was assessed by interviews at exit and its determinants were also explored by the factor score of a short list of selected items. One month's clinical records were also collected for assessing drug use performance. Combining data from the field observation and the clinical records, the determinants of drug use performance were also identified by regression analysis with three selected drug use indicators, as outcome variables. The study found there has been a government regulation framework for village health providers focuses on the entry to the market (establish the services) of both individual and facility, mainly through the administrative rules rather than legislation. The results of the field survey showed, in the four project counties, governments failed to control the quantity and distribution of the village level facilities, and those on-paper regulations were clearly not being enforced effectively. A number of reasons for this local government failure were explored and discussed. Both direct and hidden observation of clinical encounters at village health facilities found serious deficiencies in childhood illness management and drug use. The study has identified a number of factors at patient, provider, facility and system levels, which were significantly associated with task, interpersonal, and drug use performance, as well as patient satisfaction. Provider level variable and system level variables have showed a stronger association with provider performance, compared with patient level variables. The study identified key determinants of provider performance as child age and disease diagnosis at the patient level, provider age, years of practice, training, and self-perceived quality of service at provider level, and facility size, daily patient flow, fee paid to government, and availability of IMCI drugs at facility level, as well as county socio-economic status and number of supervision visits by regulators at system level.
The results of this study highlight training of village doctors on the IMCI approach as necessary, but it may not be sufficient to improve their performances if broader issues are not addressed. Based on the results of this study, the researchers recognized that China needs substantial policy changes in rural health, and reconstruction of its three-tiered health system to improve health system performance, before any intervention can be effective. The focus of IMCI strategies, therefore, should be not only training of health providers, but also establishing a sound supervision and support system, as well as involvement of the local community in providing better medical practice.
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