{'fraction_non_alphanumeric': 0.027174398855814786, 'fraction_numerical': 0.0074193260033968, 'mean_word_length': 5.608387477849971, 'pattern_counts': {'":': 0, '<': 4, '<?xml version=': 0, '>': 1, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Health professionals’ perspective on the impact of community health care reform in different regions of China

Objective Changes in supplying community health services, degree of satisfaction, and policy suggestions are presented from the perspectives of health professionals in different regions of China with the purpose of further facilitating comprehensive reform of community health services. Methods Based on geographic location and economic level of development, eight cities were selected and 12 community health service institutions were chosen by random sampling from each city. A questionnaire survey was conducted by the health professionals. Results With respect to working enthusiasm, reduction in antibiotic drug use, social image and trust of patients, more health professionals in middle and western China showed positive feedbacks than those in eastern China. With respect to preliminary results of the reform, performance and salary, and health care insurance policies, health professionals’ satisfaction levels in middle and western China were higher than in eastern China. The health professionals in middle and western China were more concerned about equipment, infrastructure and increasing training opportunities. The health professionals in both eastern and middle China accentuated improving the variety of essential drugs covered by health insurance, while health professionals in eastern China suggested performance-related payment reform. Conclusions The performance of health professionals in middle and western China was improved more significantly through comprehensive reform than that of health professionals in eastern China. For health professionals in middle and western China, it is essential to strengthen infrastructure and increase professional training, while health professionals in middle and eastern China would like to see an increase in the variety of essential drugs, and those in eastern China require strengthening performance-related payment reform.


Introduction
In April 2009, the "Opinions of CPC Central Committee and State Council on deepening the reform of the medical and health" (referred to as the "New Medical Reform") proposed that urban and rural grassroots medical and health service systems should be further improved, and that the general target of the basic public health services should be popularized [1]. In 2013, the General Office of the State Council issued the "Opinions on 6 Family Medicine and Community Health 2013;1(3): [5][6][7][8][9][10][11] Essential Drug System and New Operating Mechanism for Grassroots Health Care System." This was the second time a suggestion had been made to strengthen the construction of the grassroots health service system, with the aim of improving the service ability, and consolidating the grassroots medical and health service network [2]. However, the current status of community health services in the urban area varies from eastern China to middle and western China, as does the development of comprehensive reform. As the representative service provider, community medical personnel are important stakeholders in the comprehensive reform of community health services and key performers in improving the capacity of the community health service. Their understanding, satisfaction and suggestions regarding comprehensive reform are directly related to the implementation of community health care policy, the quality of service, and the satisfaction of the residents [3]. Comprehensive reform of community health care in eight typical cities was therefore systematically studied, and changes in community health care before and after the "New

Study subjects
Eight cities from eastern China (Hangzhou and Wuxi), middle China (Hefei, Tongling, and Wuhan), and western China (Chengdu, Baoji, and Shihezi), were sampled. Twelve community health service centers were selected for each city, using a random sampling method. A questionnaire survey was distributed to all medical personnel on duty in each community health service center.

Method
Medical students and community health service personnel were selected as investigators to collect data from the community medical personnel, following a pilot survey and the unified training of the research group. The investigation included four parts. (1) Demographic indicators, such as sex, age, and title of the medical personnel. (2) Changes in individual work after implementation of the reform, including the working environment, training opportunities, working enthusiasm, workload, revenue pressure, use of essential drugs, use of antibiotics, types of prevention and health care services, and the initiative service items. (3) Satisfaction of medical personnel after the comprehensive reform of community health care in terms of the working environment, training, income, personnel system (staffing and recruiting), essential drug system, performance appraisal, basic public health service, and medical insurance policy. The satisfaction evaluation was performed using a 5-point method ("very satisfied," "satisfied," "general," "not satisfied," and "very dissatisfied"). An "uncertain/not clear" option was also added. The degree of satisfaction was calculated by designating "very satisfied," "satisfied," and "general" as "satisfactory." (4) Suggestions of the Medical Personnel for the Improvement of Comprehensive Reform of Community Health Care.

Statistical methods
The survey data were doubly entered by EpiData 3.0 using SPSS 17.0 software for statistical analysis. The count data were analyzed by a χ 2 test with multiple comparisons of the sample rate. The inspection level of the comparison between three groups was an α=0.05 and the pairwise comparison was α=0.0125. Evaluation by medical personnel of community health care work before and after mdical reform in eastern, middle, and western China As shown in Table 1, there were significant differences in the evaluations submitted by the medical personnel regarding the working environment, training opportunities, work enthusiasm, workload, revenue pressure, proportion of essential drugs, reduction in the use of antibiotics, prevention and health care services, initiative service, income, social image, and degree of trust by residents (P < 0.05). A higher proportion of medical personnel in middle China than in eastern China held the view that the working environment, training opportunities, proportion of essential drugs, prevention and health care services, initiative service, and income were improved after the reform. The proportion of medical personnel in middle China who subscribed to the view that the prevention and health care services, initiative service, and income were improved after the reform was higher than the proportion in western China, while the proportion in western China who subscribed to the view that work enthusiasm, workload, and revenue pressure were increased by the reform was higher than the proportion in eastern and middle China. The proportion of medical personnel in western China who subscribed to the view that the essential drug proportion was increased, antibiotic use was decreased, income was increased, and social image and trust by residents were improved was higher than in eastern China.

Subject demographics
These differences were statistically significant (P < 0.0125).

Satisfaction of medical personnel in eastern, middle, and western China towards all aspects of comprehensive reform of community health care
There were no significant differences in the evaluation of working environment, training opportunities, personnel system, essential drug system, and basic public health service by medical personnel in eastern, middle, and western China (P > 0.05).
However, there were significant differences in the evaluation of primary effectiveness of comprehensive reform, income, performance appraisal, and medical insurance policy (P < 0.05).
Pairwise comparisons of the degree of satisfaction of medical personnel towards the primary effectiveness of the comprehensive reform of community health care in eastern, middle, and western China were significantly different (P < 0.0125).
Satisfaction with income in middle cities reached a maximum of 65.2%, which was higher than those in eastern (56.3%) and western cities (56.9%). Satisfaction with the implementation   Table 3).

Implementation of the comprehensive community health care reform resulted in greater improvements in the performances of community health professionals in middle and western China than in eastern China
Improvements in the performance of community health professionals in middle and western China were greater than in eastern cities, which mainly manifested as a higher work enthusiasm, a decrease in the proportion of antibiotic use, a better social image, and improvement in the degree of trust by  With respect to performance-based income reform, the related study also indicates that the current performance-based income reform of medical institutions is not perfect. First, there is a lack of an effective appraisal mechanism for performance-based income and a lack of any departmental performance management system to consider performance planning, evaluation, analysis, and improvement. Second, it is difficult to quantify the comprehensive management index and to ensure fairness. Third [9], after implementation of the essential drug system, it is difficult to implement performance-based incomesystem reform because of the decrease in the drug-related income of the community health service institutions, insufficient staffing, and incomplete government compensation [10].

Policy suggestions
The infrastructure should be strengthened, and training should be supported in middle and western China through financial transfer and regional cooperation

The essential drug system should be improved to meet the requirements of community drug use
The drug use requirement of medical personnel is a true reflection of the residents' needs. The fact that drug use requirements cannot meet the actual needs even after the implementation of the essential drug system remains a problem. It has therefore been suggested that the essential drug system should be further improved and the types of essential drugs should be increased to meet the drug-use requirements of the medical personnel. It is stipulated that community health service institutions must use the community essential drug catalogue, but should determine the proportion of drugs outside the catalogue depending on the need [11]. Financial compensation by the government for essential drugs should be implemented, thus avoiding the problem of insufficient drug supply due to incomplete drug compensation.

Reform of operating mechanisms should be further promoted, with the strengthening of reforms of performance appraisal and performance-based income system
First, regarding the performance-based income system reform, the overall income level of medical personnel should be at least equal to that before the reform. Second, international experience should be heeded. An internal assessment should be performed using indices such as the number of services,