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Health Resource Allocation in Western China from 2014 to 2018


 Background: Health equity has persistently been a global concern. As a basic material guarantee to ensure health equity, how to allocate the health resources in a fair and reasonable way has always been one of the research hotspots. The coronavirus 2019 (COVID-19) pandemic has also prompted a rethinking of the topic. Based on the previous research, western China is a relatively backward region, coupled with climate, geography, and other factors, which leading the inconvenient transportation and difficult resource allocation. However, the fairness of health resource allocation in western China has received relatively little attention. Methods: Lorentz curve, Gini coefficient and Theil index were used to analyse the health resources allocation in the western China. The indexes include number of beds, medical (assistant) practitioners, registered nurses from 2014 to 2018 through population and geography dimensions. Results: The total health resources shows an increasing trend from 2014 to 2018; The Lorentz curve in the population dimension had a smaller curvature than in the geography dimension. The Gini coefficients for health resources in the population dimension were ranged from 0.057 to 0.129, and in geography dimension the Gini coefficients ranged between 0.605 and 0.647. This shows that the distribution of Health resources is fair basing on population dimension. Furthermore, in two dimensions, the intra-group contribution rate of the Theil index was higher than in the inter-group, and the allocation of practicing (assistant) practitioners and registered nurses show a significant inequity in intra-group. This result indicated that the inequity of health resources allocation were mainly came from intra-group, namely the provinces (autonomous regions and municipalities) in western China.Conclusions: In recent years, China’s various measures have improved the total amount of health resources and its equity of health resources in western China. However, the fairness of the health resources allocation in western China were remind poor. Although the fairness of human resources allocation has been alleviated in population dimension, the inequity of human resources distribution in provinces (autonomous regions and municipalities) are still obvious. In addition, the accessibility of health resources in western China must be further improved.

Public data were collected by searching the National 2015-2019 Statistical Yearbook [14], the data released by local health commissions during 2015-2019, and Statistical Yearbook of the Western Provinces (Autonomous Regions and Municipalities) of China 2015-2019 [15][16][17][18][19][20][21][22][23][24][25][26]. According to 'The 13th Five-Year Plan for Health and Wellness', the resources in medical and health service system includes number of beds in health care facilities, medical (assistant) physician, registered nurses, general practitioners, and proportion of beds in socially run hospitals in total number of hospital beds. Considering of the data accessibility, the data collected this time were mainly include number of beds, medical (assistant) physicians, registered nurses, population, and area in western China from 2014 to 2018.

Functional regional division
The 12 provinces were divided into two areas: Ethnic minority area and non-ethnic minority areas. Ethnic minority area includes the Ningxia Hui Autonomous Region, the Tibet Autonomous Region, the Xinjiang Uygur Autonomous Region and the Inner Mongolia Autonomous Region, the rest of the provinces were divided into non-minority areas.

Measurements of inequity
Lorenz curve, Gini coe cient and Theil index have their own advantages and disadvantages in analysing health resources allocation. Comprehensive use of these analytical methods can objectively analyse the fairness of health resources allocation and determine the main factors affecting the inequity of resources allocation. Hence, the three measurements were used to analyse the equity of distribution in western of China in population dimension and geographical dimensions.

Lorentz curve
At the early period, Lorenz Curve was mainly used to evaluate the equity of resource or income distribution and measure the equity difference. Now, it is commonly used to measure the equity of health care resources [8]. Its drawing method is classi ed into people's income or resources according to different groups or regions, builds a coordinate system with the cumulative percentage of population (population dimension) or land area (geographical dimension) and the cumulative percentage of various medical resources as coordinates. Then, connected to the zero point and each coordinate point curve drawing to draw an absolute fairness line. The fairness in Lorentz is judged on the basis of its distance from the absolute fairness line. The closer it is to the absolute fairness line, the fairer it is, and the worse it is [27].

Gini coe cient
Lorentz curve can evaluate the equity of resources. However, it cannot quantify the speci c difference [28]. Therefore, Gini coe cient must be used for further accurate analysis. Gini coe cient is calculated as follows [29]: Where, G stands for Gini coe cient, N for group number, µ for resident income, Y i and Y j for per capita income of group I and J [30].
Gini coe cient value range is [0,1], the closer it gets to 0, the fairer it is. Meanwhile, the closer it is to 1, the less fair it is. It is generally believed that: Gini coe cient less than 0.3 means the resources allocation is in a best fair state;0.3-0.4 is the normal state; a level of alert above 0.4; above 0.6 is in a dangerous state of high unfairness [31,32].

Theil index
Theil index is the major instrument to measure fairness, it can directly re ect the in uence of different regions to resource allocation. Its value range is [0,1],the lower the value of Theil index, the better the balance of social resource allocation in this region [33,34]. Given that the Theil index can divide the overall variance into the differences between groups, hence, Theil index was used to analyse the health resource allocation, the equity of health resource allocation between and within different regions within the region can also be measured [35].
The calculation formula of Theil index is as follows: Where, P n refers to the proportion of the population of each province in the total population; P j is the proportion of the population of each region in the total population; Each Y n is the proportion of resources of each province in the total number of resources on this dimension. Y j shows the proportion of resources of each region in the total number of resources  Taking the cumulative population ratio as the X-axis and the cumulative percentage of health resources as the Y-axis, Lorentz curve under the population dimension was plotted, and the result was shown in Fig. 1. Similarly, the Lorentz curve under the geographical dimension was drawn with the geographical area as the X-axis and the cumulative percentage of health resources as the Y-axis. The results were shown in Figure. 2. Compare Lorentz curves in two dimensions, the curve in the geographical dimension was signi cantly distant from the absolute fairness line than in the population dimension, which indicates that the allocation of health resources in population dimension is better than that in geographical dimension. Moreover, the bending degree of Lorentz curves of the three analysis indicators in the population dimension is similar, indicating that the difference in fairness degree is small. The Lorentz curves of the three analysis indicators in the geographical dimension shows similar results.
Gini coe cient of health resources in western China from 2014 to 2018 Gini coe cients were calculated respectively according to the Lorenz curve drawing results of population and geographical dimensions, as shown in Table 3.
In In addition, Fig. 3 exhibits that the Gini coe cient in the population dimension presents a downward trend, which indicated that that equity has improved.
Meanwhile the Gini coe cient on the basis of the geographical area, presents an overall gradual upward trend, as shown in the Fig. 4.

Theil index of health resources in western China
Based on the Theil index analysis of different dimensions shown in Table 4, Theil index in population dimension is lower than that in geographical dimension, which indicates that the allocation of health resources in population dimension is better. Moreover, it can be seen from the analysis results of Theil index contribution rate of health resource allocation from the two dimensions in Table 5,the Theil index in the two dimensions shows a status of intra-group higher than inter-group. From the perspective of population dimension, the three indexes were all showed that the intra-group contribution rate greater than the intergroup contribution rate, and the contribution rate were all reached more than 70%. Among them, the contribution rate of practicing (assistant) physicians and registered nurses in population dimension was the most obvious. The above results indicate that the inequality of resource allocation mainly comes from intra-group, namely inside the provinces (autonomous regions, municipalities), and the inequity allocation of human resources (practicing (assistant) doctors and registered nurses) is obvious. The contribution rate in geographical dimension shown a similar tendency, and the rate has reached above 60%.  (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 coe cient 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][49][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, tra c 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][55][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 insu cient. 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 di cult for staff to adapt. In addition, there are many