Table Of ContentZouetal.BMCHealthServicesResearch2012,12:21
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RESEARCH ARTICLE Open Access
Factors influencing integration of TB services in
general hospitals in two regions of China: a
qualitative study
Guanyang Zou1, Xiaolin Wei2*, John D Walley3, Jia Yin1 and Qiang Sun4
Abstract
Background: In the majority of China, the Centre for Disease Control (CDC) at the county level provides both
clinical and public health care for TB cases, with hospitals and other health facilities referring suspected TB cases to
the CDC. In recent years, an integrated model has emerged, where the CDC remains the basic management unit
for TB control, while a general hospital is designated to provide clinical care for TB patients. This study aims to
explore the factors that influence the integration of TB services in general hospitals and generate knowledge to aid
the scale-up of integration of TB services in China.
Methods: This study adopted a qualitative approach using interviews from sites in East and West China. Analysis
was conducted using a thematic framework approach.
Results: The more prosperous site in East China was more coordinated and thus had a better method of resource
allocation and more patient-orientated service, compared with the poorer site in the West. The development of
public health organizations appeared to influence how effectively integration occurred. An understanding from
staff that hospitals had better capacity to treat TB patients than CDCs was a strong rationale for integration.
However, the economic and political interests might act as a barrier to effective integration. Both sites shared the
same challenges of attracting and retaining a skilled workforce for the TB services. The role of the health bureau
was more directive in the Western site, while a more participatory and collaborative approach was adopted in the
Eastern site.
Conclusion: The process of integration identifies similarities and differences between sites in more affluent East
China and poorer West China. Integration of TB services in the hospitals needs to address the challenges of
stakeholder motivations and resource allocation. Effective inter-organizational collaboration could help to improve
the efficiency and quality of TB service. Key words: TB control, service delivery, integration, hospitals, China.
Keywords: TB control, service delivery, integration, hospitals, China
Background course chemotherapy; regular drug supply; and monitor-
Integration of TB services into general health services ing and evaluation [1]. WHO and International Union
Tuberculosis (TB) control is of great public health against TB and Lung Disease (IUATLD) have strongly
importance, particularly in many low-and middle- recommended that TB and other disease control pro-
income countries. The World Health Organization grammes should be closely integrated within wider
(WHO) TB strategy, brand named “DOTS”, is based on health systems. However, in many countries national TB
five essential elements: political commitment; case programmes function vertically as part of the commu-
detection using sputum microscopy; standardized short nicable disease control system, operating outside the
existing health care structures [2]. Raviglione and Pio
suggest that this integration should be through “a prag-
*Correspondence:[email protected]
2TheChineseUniversityofHongKong,2/F,SchoolofPublicHealthand matic approach combining a specialized, well defined
PrimaryCare,PrinceofWalesHospital,Shatin,N.T.,HongKong,China management system with a fully integrated service
Fulllistofauthorinformationisavailableattheendofthearticle
©2012Zouetal;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons
AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin
anymedium,providedtheoriginalworkisproperlycited.
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delivery” [3]. Unger et al defines integration as “a pro- funding, both the hospital sector (largely public) and
cess where disease control activities are functionally public health organizations had to rely on providing
merged or tightly coordinated with multifunctional additional services and selling drugs to subsidize their
health care delivery” [4]. In particular within this paper, total income [14]. During this time, TB control, as with
integration is used to describe the inclusion of TB con- many other public health activities, was neglected as it
trol activities, especially clinical services, into general was labor intensive and created little income [12].
health services. Where TB diagnosis and treatment was provided for
Integration of TB services into primary health care has free, many CDCs charged patients for additional tests
been common since the 1970s [5], however this has and drugs, often with uncertain benefit [12,16].
been less successful within secondary health care. Invol- China’s TB control has benefited from a series of mea-
ving public and private hospitals for effective TB pro- sures to strengthen the public-health system following
gramme delivery is part of WHO’s Stop TB strategy the outbreak of severe acute respiratory syndrome
called Public-Private Mix (PPM)-DOTS [6]. Although (SARS) in 2003 [12]. Since 2003, there has been signifi-
integration of TB services within public and private hos- cantly increased funding for public health, especially for
pitals in many African countries has been achieved, this TB. In 2004 the law on the control of infectious diseases
has been less successful in parts of Asia where hospitals was revised, and the national internet-based communic-
were not included in initial plans for rapid TB service able disease reporting system was implemented to
expansion [7]. Indonesia is one example of an Asian ensure cases of TB are reported. By 2005, China
country where DOTS is increasingly included within achieved the global targets for TB control, with com-
public and private hospitals [8-11]. Despite the success- plete DOTS coverage, 80% of new smear-positive TB
ful scale-up, hospitals have reported lower cure and suc- case detection, and over 90% treatment success rate
cess rates, compared to chest clinics and health centres [12].
[8], with a large proportion of patients not treated with
standardized diagnosis and treatment [9]. In order to Integration of TB services: from the CDC model to the
strengthen integration of DOTS within hospitals, a com- integrated model
bination of strong individual commitment of health pro- In the majority of China, the county CDC provides both
fessionals, organizational supports, partnership clinical (diagnosis, treatment and clinical management)
governance, and relevant policy is required [9]. and public health functions (education, supervision and
reporting) for TB cases. General hospitals and other
TB control in China health facilities such as community-based health services
China has one of the highest TB burdens in the world, are required to refer suspected TB cases with cough of
with more than 1.3 million new cases each year [12]. two weeks or more or haemoptysis to the CDC. Only
The Centre for Disease Control and Prevention (CDC) complicated and severe TB cases are treated in the gen-
at various levels was established during the national eral hospitals. The CDC traces all referred cases not vis-
health sector reform since early 2000, by incorporating iting the CDC within three days. Only TB patients
previous anti-epidemic stations and related public health registered and treated in the CDC are entitled to free
programmes [12]. Accordingly, many TB dispensaries treatment under the government’s TB programme. This
were merged into the CDC as an affiliated department model is known as “CDC model”.
or a department combined with other public health pro- This model to TB services has come across a number
grammes. The national CDC, under the leadership of of challenges. Thirty-four percent of patients with a TB
the Ministry of Health, provides technical support and diagnosis first presented at the general hospital system
routine management of disease control programmes, after the onset of their symptoms. However, only 25% of
including the National TB Programme (NTP). This these cases were reported and 13% referred to the CDC
structure is replicated at provincial, prefecture and [17]. As a result, a large proportion of patients have not
county levels [13]. been seen within CDC DOTS services. Another concern
Before 2003, TB control performance was poor, with is the low adherence to TB diagnosis and treatment
detection of smear-positive TB at around 30%[12]. The guidelines in hospitals, with treatment often including
inadequate control of TB was related to a malfunction- unnecessary prescriptions [18]. In addition, the CDC has
ing health system, which resulted from the transition to limited staff and clinical capacity [19], particularly after
a market economy and financial decentralization in the the enactment of the Law for Licensing Medical Practi-
mid-1980s [14]. Since then, health funding and manage- tioners which states that public health doctors are not
ment responsibilities were decentralized from central eligible to provide clinical care.
and provincial governments, to county and township Since early 2000s an integrated model of TB service
governments [15]. Due to diminished government delivery was implemented in some eastern provinces
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such as Shanghai, Zhejiang and Jiangsu, on their own districts which initiated the integrated model on their
initiatives and some of the western provinces with sup- own initiative, as a bottom-up approach was thought to
port from the Global Fund to Fight AIDS, Tuberculosis be more replicable and sustainable. At the time of this
and Malaria (GFATM). In this model, the CDC con- study, very few districts in China had implemented the
tinues to provide public health functions such as referral integrated model. Thus research sites were pragmatically
management, reporting, staff training and case tracing. selected, considering the availability of the sites and
A general hospital was “designated” to undertake diag- their willingness to participate. Finally, two districts
nosis, prescription and follow-up management, with were selected from the database of the China National
other hospitals and health facilities referring those sus- TB Programme. One was Changning, a district of
pected of having TB to the designated hospital. A com- Shanghai (SC), and another was Nanning, the capital
parison of the TB functions between the two models is city of Guangxi(GN). Geographically, they are located in
summarized in Table 1. eastern and south western China respectively. SC had
To date, a few studies in China have reported the much higher GDP per capita and TB expenditure per
experience of integrating TB services in the township person than GN. Both sites had similar cure rates of
hospitals (functioning as health centers) of Guangxi new smear positive TB cases (Table 2). A prefectural
[20,21], Shandong [22,23] and Gansu provinces [24]. general hospital in GN provided TB services since 1996
However, there is a lack of published evidence on the but it was not until 2005 that TB services were fully
integration of TB care in the general hospitals. This integrated in this hospital. In SC, TB services were inte-
study aims to explore the factors that influence the inte- grated in a district general hospital in 2007. Under the
gration process and generate knowledge for the scale-up leadership of health bureaus, the designated hospitals in
of the integrated model in China. It is one of the first both sites work with the CDCs at the same levels, and
few studies which research the integrated model in other general health facilities to deliver TB service
China. This study will not only provide evidence for the within their catchments areas.
implementation and scale-up of the new policy in
China, but also adds to the currently limited research Data collection
on integration of TB service in the larger public or pri- Purposive sampling techniques were employed to select
vate hospitals in similar settings. participants based on their disciplines and roles. These
individuals represented a wide spectrum of health pro-
Methods fessionals working within TB control. 21 individual
This study adopted a qualitative approach, particularly interviews were conducted, 11 at SC and 10 at GN, in
valuable when seeking to explore processes of imple- the autumn of 2008 (Table 3). The interviewees
mentation [25]. included: directors of the CDC, the designated hospital,
and another general hospital; CDC staff responsible for
Research sites the service delivery; and practitioners from departments
In order to better understand the drivers and barriers of of the laboratory, outpatient, and patient wards of the
policy implementation, we chose sites from different designated hospital and another general hospital. A
economic development regions for this study, i.e. from semi-structured topic guide was developed and used for
the East and West provinces. Although GFATM sup- the interviews, covering topics including background
ported districts might exist, we purposefully selected and history of integration, and process of integration,
Table 1Comparison ofTBfunctions between the CDCandintegrated model
Functions TheCDCmodel Theintegratedmodel
IdentifysuspectedcasesofTB Allhealthfacilities Allhealthfacilities
DiagnoseandconfirmTB CDC Designatedhospital
PrescribetreatmentforTB CDC Designatedhospital
Performclinicalfollow-up CDC Designatedhospital
Recordandreportcases CDC Designatedhospital
Supervisetreatmentorassigntreatmentobserver Community-based Community-based
healthfacilities healthfacilities
Followupondefaulters,trainhospitalstaff,supervisenetworks,laboratoryEQA,monitorand CDC CDC
evaluate,providesuppliesandmedicine
NB:Inthebothmodels,community-basedhealthservices,ie,townshiphospitalsandvillageclinicsplayanimportantroleinTBcontrol.However,theirrolesare
onlylimitedonreferringtheTBcasesorsuspectstotheCDCorthedesignatedhospital,supportingtheCDCtoconductthedefaultertracing,andproviding
treatmentsupervisionsfortheTBpatients.
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Table 2General social economic situations andhealth financing forTB inShanghai Changning andGuangxi Nanning
(2007)
Indicators ShanghaiChangning GuangxiNanning
PercapitaGDP(RMB) 88,785 15,774
TBexpenditureperperson(RMB) 0.99 0.42
NotificationrateofTBpatients(permillion) 322 999
CurerateofnewsmearpositiveTBcases(%) 88.5 89.8
Numberofgeneralhospitalsinthedistrict 10 46
including health financing, leadership, service delivery, transcripts were scrutinized to identify emerging and
task mix and communication. recurrent themes and a framework table was progres-
The interviews were conducted by a core research sively established and structured. These themes and
team, mainly consisting of TB researchers from the Uni- sub-themes were input into the tree-structure of Weft
versity of Leeds based in China (XW, GZ and JY) and QDA. Transcripts of each interview were read through
Shandong University (QS). One member was responsible and coded into the related themes and sub-themes.
for ensuring consistency throughout the data collection Coding was an iterative process which permitted to
process. Interviewees were invited for interview through revise the existing themes and include emerging themes
the CDC and appointments made via telephone or from the data. Table 4 illustrates examples of the coding
Email, outlining the purpose of the research and ques- process. The analysis was carried out by two different
tions to be asked. Informed consent was obtained prior persons within the research team (one conducted the
to the interviews. Each interview lasted approximately initial analysis, while another checked the appropriate-
40-50 minutes, and was audio recorded with permission ness of the coding and categorizing). A structured,
of the interviewees. The recording was transcribed focused approach was used which helped to identify
within 48 hours by trained postgraduate students from similarities and differences across the two sites [25].
Shandong University and checked by at least one core
research team member. This ensured that researchers Validity and reliabilityof the study
could return the unclear points of the transcripts to the In qualitative research, participant and researcher bias
interviewees for clarification in a timely manner. Ethical may affect the validity and reliability of findings. Efforts
approval was granted by the Ethical Committee of were made to overcome the sources of biases which
School of Public Health of Shandong University. could derive from questions design, sampling, data col-
lection and analysis [27]. Working in a team for the
Data analysis data analysis provided a form of triangulation [27-29].
A thematic approach was used, which allows both appli- Another two members who were not involved with data
cation of an existing framework and inclusion of further analysis revisited the emerging themes and refined their
emerging themes from the data [25]. All the data relationships. Another member of research staff, not
sources were imported into the Weft QDA, a computer- involved with this study, was invited to check for the
assisted qualitative analysis tool. The topic guides and consistency of the original themes and the themes
Table 3Sampling forthe in-depth interviews in Shanghai Changning and GuangxiNanning
Organisation Positions ShanghaiChangning GuangxiNanning
CDC Director 1 1
TBsectionchief 1 1
Director 1 1
Outpatientdoctor 2 1
Designatedhospital Inpatientdoctor 1 1
Laboratorystaff 1 1
Radiologystaff 1 1
Publichealthstaff 1 1
Othergeneralhospital Directors 1 1
Outpatientstaff 1 1
Total 11 10
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Table 4Examplesofthe coding process(translated)
Transcripts Condensedmeaning Sub-themes Themes
“OurdoctorsnormallywouldnotadmitthegeneralTB “DoctorsnormallynotadmitthegeneralTBpatients, impactof resource
patientsandreferralofsevereTBpatientsistheir referralofsevereTBpatients,otherpatientswill resource allocation
responsibility.IfweadmitthegeneralTBpatients,other complainadmittingthegeneralTBpatients,migrant allocationon
patientswillcomplain.Especiallythemigrantpatients, patientsdidnothavemedicalinsurance.” hospitalization
[who]donothavemedicalinsurancesotheycan’tbe (patient-
reimbursedfortheinpatientcost”.(SC,hospitalstaff) centredness,
publichealth
approach)
“Thehealthbureauorganizes4-5specialmeetingsfor “Healthbureauorganizes4-5specialmeetingsannually, roleofhealth management
theCDCanddesignatedhospitalannually.The coordinationfromhealthbureaueffective,hospital bureau coordination
coordinationfromhealthbureauiseffective.For minimizedcasemanagementallowance,healthbureau relationship
example,thehospitaltriedtominimizethedistribution solvedproblem,coordinationbetterandbetter.” betweenCDC
ofthecasemanagementallowance(tocommunity andhospital
doctors)anditwasthehealthbureauthatsolvedthe
problem.Ourcoordinationwithhospitalisgenerally
gettingbetterandbetter.”(GN,CDCstaff)
arising from his understanding. Any discrepancies aris- TB services were integrated into the designated hospital.
ing within the team and between the team and the This process coincided with the enactment of the Law
external reviewer were addressed through the consensus. for Licensing Medical Practitioners in the late 1990s,
This process in return improved our insight of the origi- which made public health doctors become ineligible to
nal context and understanding of the transcripts. provide clinical care.
Results 2. Clinical capacity
Seven categories of factors which influenced TB service The capacity of CDC staff to treat TB patients remained
integration were: historical context, clinical capacity, challenging, reflecting the practical need for such inte-
motivation for integration, resource allocation, incentive gration. For example, the doctors in GN’s designated
and staffing, management coordination, and technical hospital criticized the CDC doctors’ lower clinical capa-
exchange. city, and poorer knowledge on complications such as
liver damage and respiratory failure. The CDC staff
1. Historical context seemed to agree with such criticism and suggested that
In both sites, the integration process was found to be integration could make the best of the public health
contingent on the restructuring process of the public strength of the CDC and the clinical strength of the
health organizations (Table 5). This restructuring pro- hospital.
cess reflected the continuous health sector reform under
the context of financial decentralization in China, “It was difficult for us to treat TB patients, with lim-
including the establishment of the CDCs in early 2000. ited technology, equipment and staff. We are espe-
This whole process had witnessed the weakening of the cially not confident in treating the complications.
clinical functions of the CDCs and redeployment of the After the clinical function was transferred to the hos-
TB control staff to the designated hospitals. Since then, pital, we could focus more on management... We are
Table 5Organizational transition in Shanghai Changning andGuangxiNanning
ShanghaiChangning GuangxiNanning
InSC,therewasanindependentTBdispensarydirectlyaffiliatedtothe InGN,earlyin1996,TBclinicalservicewasco-providedbyan
healthbureaubefore1995.However,thedevelopmentofTBdispensary independentTBdispensary,aprefecturalgeneralhospital,amedical
waschallengedbythediminishedgovernmentfunding.In1995a universityaffiliatedhospital,aprovincialhospital.However,itwas
chronicDiseaseControlInstitutewasestablishedandTBdispensarywas recognizedthatthecomplexityofTBservicedeliverystructurehad
mergedintothisinstitute.In2000,followingthenationalhealthsector resultedinthepoorcoordinationandmanagementofTBcare.In2002,
reformtheCDCwassetupandthechronicdiseasecontrolstationwas theprefectureCDCwasestablishedfollowingthenationalreform,
mergedintotheCDC.In2007,theCDCwasmovedintoanewpublic incorporatingtheanti-epidemicstation,healtheducationinstituteand
healthbuilding,whereconductingTBclinicalactivitiesseemednolonger theTBdispensary.In2005,theprefecturalgeneralhospitalwas
appropriate.Bythattime,mostoftheotherdistrictsinShanghaihad designatedtofullyprovidetheTBservice,andalltheTBcases/suspects
adoptedtheintegratedmodel.Attherequestofthehealthbureau,a wererequiredtobereferredtothishospitalforstandardizedtreatment
districtgeneralhospitalwasdesignatedtoprovideTBservice. andmanagement.
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public health doctors so we should do more on epide- project funding from the Ministry of Health (MoH),
miology and health education.” (GN, CDC staff) matched by local government. However, some felt that
this funding was too limited to cover costs of service
operation and were concerned about the approach to
3. Motivation for integration budget allocation which was often reallocated from the
The initial integration process faced some barriers. It CDC.
was apparent that there was a lack of motivation of staff
to move towards the integrated model within the CDCs. “We have to pay extra money to buy a mini-car to
Interviews suggested that political will and economic conduct patient supervision activities and pay the
interests would be potential barriers to integration. One associated costs from our general budget. We also
member of CDC staff in SC expressed they favored the need to subsidize the associated staff and electricity
CDC model, which allowed them to better control the costs to conduct the X-ray service for TB diagnosis.
affiliated TB clinic. The CDC staff from GN reported The more we do, the more we have to pay from our
that they did not want integration initially, complaining own pocket... I believe there will be further support
this would mean “sacrificing” their service. from the government when the Project comes to a
close but the key issue is how to allocate the TB con-
“We did not agree to take this approach initially. trol budget to the hospital in the most effective way.”
Although treatment of the smear-positive patients (GN, hospital staff)
was free, we could still charge from the smear-nega-
tive patients. We (CDC) were just set up at that This difficulty with funding may have contributed to
time, with very constrained funding. We could have the hospital attempting to make additional money from
supplemented the funding through TB treatment. We treating TB patients, such as prescription of unnecessary
made great sacrifice through the integration initia- drugs and hospitalization. Although staff suggested that
tive. At that time, we were located in the same yard only serious TB cases were admitted, the estimated
with the hospital. Both hospital staff and we (CDC annual hospitalization rate of the TB patients was up to
staff) waited outside the doors to ‘compete’ for TB 20%. CDC staff were concerned that this would increase
patients (laugh...) But we gradually accept this reality the financial burden of TB patients and may lead to
with the increasing funding from the government.” multi-drug resistant TB due to the improper treatment.
(GN, CDC staff) However, CDC staff were just sympathetic to the hospi-
tal’s financial dilemma:
Motivation for integration appeared to be mixed
within the two hospitals. GN’s hospital began to treat “Hospitals are not fully funded by the government; it
TB in 1996. Some recalled they did not want to take is understandable to have a higher hospitalization
over the full TB service as the funding was rather lim- rate but they just admit too many. But what can we
ited to support their activities. On the other hand, some do? We could only open an eye and shut an eye as
seemed to be happy with full integration as they thought long as the patients are willing to afford. See, hospi-
treatment of TB could improve their reputation and tal directors always mention money.” (GN, CDC
increase the hospital revenues. In SC, a smooth transi- staff)
tion process was observed in the hospital. By 2000,
other districts of Shanghai had set up the TB clinics in In SC, service operation has benefited from a more
the general hospital which may have motivated the local sustainable resource allocation system. The health
hospital to take over the TB service. In addition, as a bureau directly allocated the operational budget to the
designated hospital for other infectious diseases such as designated hospital and funded the TB clinical staff. The
hepatitis, they had already established a good relation- hospital mandated that severe TB patients should be
ship with the CDC. Lastly, the health bureau agreed to referred to the specialist lung hospital or other infec-
allocate the related TB control budget, previously allo- tious disease hospitals for treatment. Since funding was
cated to the TB clinics of the CDC, to the TB clinics not a major concern, there was little sign of unnecessary
within the designated hospital, with staff costs met by hospitalization of TB patients. Rather, interviews
the district government. These factors are likely to have revealed a more friendly and patient-orientated service
contributed to the smooth transition in SC. provision in SC:
4. Resource allocation “Our doctors normally would not admit the general
In GN, the hospital received limited funding from the TB patients and referral of severe TB patients is
health bureau from 1997 to 2003. Since 2004, it received their responsibility. If we admit the general TB
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patients, other patients will complain. Especially the graduates to work here, neither the payment nor pro-
migrant patients, [who] do not have medical insur- mising future of the TB work.” (GN, hospital staff)
ance so they can’t be reimbursed for the inpatient
cost”.
6. Management coordination
In both sites, an integration hospital leadership group
5. Incentives and staffing was established including leaders and experts from the
Interviews in both sites identified a difficulty in attract- health bureau, CDC and hospitals. This group met regu-
ing and maintaining skilled TB staff. In both sites, both larly to discusses the strategic issues, service coordina-
the doctors and nurses rotated from the infectious dis- tion and emerging problems of TB control.
ease or respiratory departments on a regular basis. In SC, some CDC staff thought such official meetings
There was serious concern over staffing turn-around could not address problems effectively. They seemed to
and its effect on quality of service: less rely on formal meetings and the health bureau to
solve problems, but more on personal relationships:
“We are anxious about the quality of service since no
doctors are willing to work in the TB clinics for a “Only for the bigger issues, we would invite the health
longer term. The performance is satisfactory now, but bureau to coordinate. Once we ruin the personal
there is crisis in the long run.” (SC, CDC staff) relationship with the hospital, nothing can be
done."(SC, CDC staff)
The perceived reasons for an unstable TB team in the
hospital included a concern about payment and the In GN, staff also agreed personal relationships were
potential transmission of TB. For example, TB doctors important, but they emphasized a lot on the official
in both sites thought they did not receive fair pay from coordination from the health bureau which was deemed
the hospital regardless of their qualifications and experi- effective to solve problems. As reported earlier, there
ences and the potential transmission risks from TB. was a lasting competitive relationship between the hos-
They attributed the unfair pay to the fact that the per- pital and the CDC due the economic reasons. The
formance-based payment system was not allowed in the health bureau might have thus worked as an effective
TB clinics: mediator between the two parties.
“I feel unfair as a senior physician since there was no “The health bureau organizes 4-5 special meetings for
major difference for the payment between staff work- the CDC and designated hospital annually. The coor-
ing in the TB department.” (GN, hospital staff) dination from health bureau is effective. For example,
“TB clinical staff received a ‘bonus’ from the respira- the hospital tried to minimize the distribution of the
tory department. The amount was much less than case management allowance (to community doctors)
that for staff working in the wards, albeit they had and it was the health bureau that solved the pro-
the same qualifications and experience.” (SC CDC blem. Our coordination with hospital is generally get-
staff) ting better and better.” (GN, CDC staff)
Other reported reasons for an unstable TB team
included poor infrastructure, poor job prospects and 7. Technical exchange
lack of “preferential” policy (i.e., special incentives) for In GN, TB staff in the hospital attended the general TB
the staff working in the communicable disease control training sessions organized by the CDC. The hospital
of the hospital. also organized five to six training workshops for the TB-
related staff per year. In SC, however, more collaborative
“It is not possible to talk about the preferential pol- and participatory approaches were observed. At the dis-
icy. See, our clinical building was the shabbiest in trict level, the CDC organized a multi-disciplinary group
the hospital, without a waiting room. Most of the of TB-related health professionals to discuss TB diagno-
patients wait under the tree; other departments at sis and the quality of x-ray examinations on a weekly
least have waiting rooms.” (GN, hospital staff) basis, including doctors from the respiratory and radi-
“The infectious disease allowance was too humble to ological departments of the designated hospital, commu-
attract medical staff to work for the TB clinic. It was nity health centers and other general hospitals. This
the shrinking job market that brought young approach was likely to have filtered down from higher
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level CDC working culture, where the CDC at the muni- influence how effectively integration occurred. In addi-
cipal level organized multi-disciplinary consultation tion, an understanding by staff that hospitals had better
meetings on the monthly basis. These meetings allowed capacity to treat TB patients than CDCs was a strong
TB doctors from all the designated hospitals to rationale for integration. However, the economic and
exchange their experiences of TB diagnoses and treat- political interests might act as a barrier to effective inte-
ment. The hospital staff in SC also felt that they gration of TB control. The more prosperous site (SC) in
received sufficient technical support from the district Eastern China was more coordinated and thus had a
and municipal CDC during the initial period of integra- better method of resource allocation and more patient-
tion: orientated service, compared with the poorer site (GN)
in the West. Both sites shared the same challenges of
“The public health doctor of the district CDC came attracting and retaining a skilled workforce for the TB
to guide our sputum test once per month in the first services. The role of the health bureau was more direc-
six months. Experts of the municipal CDC also came tive in the poorer West, while a more participatory and
to check the quality of smears and sputum culture collaborative approach was adopted in richer East
(three times).” (SC, hospital staff) China.
The similarities and differences of the two sites in the Policy implications
process of integration are summarized in Table 6. Our results adds to existing research on factors that
influence integration of TB into hospitals [8-11]. These
Discussion factors reflected the importance of motivation, resources
Summary of findings and collaboration in the process of integration, although
This study aimed to investigate the factors that influ- historical context may play an important role in shaping
enced the process of integration of TB service from change [26]. These findings may have important policy
health care professionals’ perspectives. The development implications for the implementation and scale-up of the
of public health organizations and the enactment of the integrated model in China or other similar health care
Law for Licensing Medical Practitioners appeared to settings.
Table 6Factors influencing the integration ofTBservices inShanghai Changning andGuangxi Nanning
Themes ShanghaiChangning GuangxiNanning
Historical Integrationassociatedwiththerestructuringprocessofthepublic Integrationassociatedwiththerestructuringprocessofthe
context healthorganizations,especiallytheestablishmentofCDC publichealthorganizations,especiallytheestablishmentof
PressurefromenactmentoftheLawforLicensingMedical CDC
Practitioners. PressurefromenactmentoftheLawforLicensingMedical
Practitioners.
Clinical LimitedcapacityoftheCDCstafftotreatTBcases:rationalefor LimitedcapacityoftheCDCstafftotreatTBcases:rationale
capacity integration forintegration
Motivation CDC: CDC:
for Worriedaboutlosing“control”ofservices:apotentialbarrier Worriedaboutlosing“profits”ofservices:apotentialbarrier
integration
Hospital: Hospital:
Strongbudgetcommitmentfromhealthbureaumaymotivate Littlebudgetcommitmentfromhealthbureaumay
providers demotivateproviders,butintegrationperceivedtoimprove
Historicalinfluence:alreadyestablishedgoodrelationshipwiththe reputationandincome
CDCbeforeintegration Historicalinfluence:involvingTBserviceprovisionsince1996
Environmentaltrigger:mostoftheotherdistrictsinShanghaihad
adoptedtheintegratedmodel
Resource Moresustainableresourceallocationsystem:healthbureaudirectly Fundingforthedesignatedhospitalratherlimited,resources
allocation allocatedoperationalbudgettodesignatedhospitalandfundedTB reallocatedfromCDCtodesignatedhospital;
clinicalstaff TendencytohospitalizeTBcases,moreprofitandclinical-
Morepatient-centeredandpublichealthorientatedcare:may orientatedcare:mayaffectthequalityofintegration
improvethequalityofintegration
Staffingand AttractingandmaintainingskilledTBstaffachallenge AttractingandmaintainingskilledTBstaffachallenge
incentives
Management Leadershipmechanismsinplace Leadershipmechanismsinplace
coordination Personalrelationshipscount Officialcoordinationfromthehealthbureaucounts
Technical Participatoryandcollaborativeapproach:mayhelptoimprovethe Traditionaltrainingapproach:maylimitthequalityof
exchange qualityofintegration integration
Zouetal.BMCHealthServicesResearch2012,12:21 Page9of11
http://www.biomedcentral.com/1472-6963/12/21
The TB programme has long been working in parallel of the TB control budget from the CDC. Integration
with the general health services. Integration not only requires transfer of funds for care from the CDC to the
involves the shift from a specialized organization to a hospital. An appropriate budgeting mechanism needs to
horizontal one, but also a real transfer of responsibilities, be explored to ensure equitable allocation of resources
rights and duties [30]. In order to achieve this, chal- and successful integration as in the case of SC.
lenges which affect the motivation of both the CDC and Different practices of hospitalizing TB patients in SC
hospital staff for integration should be addressed. and GN could also reflect the conflicts between the clin-
Within the CDC, it is important to address the concern ical and public health perspectives of TB care delivery.
arising from the “loss” of the TB service. The CDC staff Clinicians in the hospital should be educated to improve
in SC worried about “losing control and power” over the public health awareness, and specifically implement
the vertical service, as operating the service directly was an outpatient-based systematic public health TB
thought to be easier than collaborating with the hori- approach. Both sites presented the challenges of retain-
zontal health service [30]. In GN, the “loss” of the TB ing qualified TB personnel. To ensure that TB services
service meant losing profit for CDC. This suggests that are sustainable and maintain a high quality of care, fair
under-resourcing of the CDC may have been a barrier pay should be provided to attract and stabilize a moti-
to supporting integration, particularly true in West vated and skilled workforce.
China where costs were not fully met by the local gov- Successful integration relies on effective inter-organi-
ernment [15,16,18,22]. Within the hospital, historical sational collaboration, which could contribute to the
involvement in TB services, good relationships with the efficiency and the quality of TB services by combining
CDC and an encouraging integration environment prior resources and expertise from different organizations
to integration may help to improve the process of inte- [33]. Recent work in Indonesia suggests that strengthen-
gration. Integration itself can sometimes provide positive ing the collaboration between the TB programme and
incentives since provision of TB service may improve hospitals by involving hospitals in DOTS implementa-
reputation and income for hospitals [9]. However, tion has potential to improve TB control [8-11]. Follow-
experiences from the two sites suggest a strong political ing the integration, the hospital has changed its role
commitment from health bureau is the key to motivate from “reporting and referral” to clinical service provi-
and engage the hospitals. sion, while they are well placed to do so [13]. Integra-
Resources are vital to ensure successful service inte- tion means making the best of the public health
gration [11,31]. The hospital in SC appeared to have strength of the CDC and clinical strength of the hospi-
more patient-centered care, while the hospital from GN tal, which requires a higher degree of inter-organiza-
appeared to be more profit-oriented. It is suggested that tional collaboration to ensure successful integration. A
these differences in mentality were due to differences in more collaborative and participatory inter-organizational
resource allocation systems, and security of funding. Fol- approach was observed in the more affluent Eastern
lowing the financial decentralization, performance-based China site. This was probably due to a participatory
payment systems have been prevalent in Chinese public learning culture and the historically better relationship
hospitals, which may have encouraged gaming within between the designated hospital and CDC. In the poorer
the health system to raise additional funds by charging Western China site, however, the CDC and hospital had
from patients [32]. This approach is not encouraged in long-lasting competitive relationship often due to chal-
the TB clinics, however it is entrenched within practice lenges in resource allocation and poor communication.
as operational costs are not fully met by the govern- Such competitive relationship may fuel a degree of mis-
ment. Loss of income due to free TB treatment policy trust, thus damaging the collaboration [11]. Experiences
may be a universal concern [11]. Hospital providers may from both sites highlight the importance of dialogue
thus comprise the standardised TB treatment through and flexibility [34,35], informal communication [11,36],
unnecessary prescription of drugs, tests and admissions and good governance [11,34] to sustaining such colla-
for general TB patients. These distorted incentives con- boration. A powerful intermediary actor, such as health
strain the patient-orientated care provision and can bureau can play a positive role in mediating such colla-
negatively impact on the care of patients. While govern- boration [11].
ment funding has largely improved for public health
facilities such as CDC, there is an urgent need to Limitations
increase funding to subsidize the newly integrated pub- Experiences from the two sites may not be generalizable
lic-health services in the hospital. The resource alloca- within China, although they provide common but dis-
tion mechanisms in TB control seemed to favor the tinctive discussions around the drivers and barriers to
CDC, and so hospitals may suffer from a “reallocation” service integration. This study is limited on the
Zouetal.BMCHealthServicesResearch2012,12:21 Page10of11
http://www.biomedcentral.com/1472-6963/12/21
discussion of the process of integration, though a con- References
current study is being conducted to compare the pro- 1. WHO:AnexpandedDOTSframeworkforeffectivetuberculosiscontrol.
Geneva:WorldHealthOrganisation;2002.
cess and effect of implementing the integrated model
2. AtunRA,Lennox-ChhuganiN,DrobniewskiF,SamyshkinYA,CokerRJ:A
with the CDC model in China. This study only focused frameworkandtoolkitforcapturingthecommunicabledisease
on the collaboration between the CDC and designated programmeswithinhealthsystems:tuberculosiscontrolasan
illustrativeexample.EuropeanJournalofPublicHealth2004,14(3):267-273.
hospital and neglected other important aspects of inte-
3. RaviglioneM,PioA:EvolutionofWHOpoliciesfortuberculosiscontrol,
gration, such as the internal management of the desig- 1948-2001.TheLancet2002,359(9308):775-780.
nated hospital, the collaboration between the designated 4. UngerJP,DePaepeP,GreenA:Acodeofbestpracticefordisease
controlprogrammestoavoiddamaginghealthcareservicesin
hospital and other general health facilities including pri-
developingcountries.InternationalJournalofHealthPlanningand
mary health care organizations. However, we believe Management2003,18(Suppl1):S27-39.
that the relationship between the CDC and designated 5. AtunR,WeilDEC,EangMT,MwakyusaD:Health-systemstrengthening
andtuberculosiscontrol.TheLancet2010,375(9732):2169-2178.
hospital is the best entry point to understand the issues
6. WHO:EngagingallhealthcareprovidersinTBcontrol:guidanceon
of integration. This study cannot escape the subjectivity implementingthepublic-priviatemixapproaches.Gevena:WorldHealth
and recall bias inherent qualitative studies. However, Organisation;2006,54.
7. OhkadoA,UplekarM,AriasM,VoskensJ:GuidingPrinciplesandPractical
efforts have been made to improve the reliability and
StepsforEngagingHospitalsinTBCareandControl:USAIDTBCTA2009.
validity of the study findings. 8. IrawatiSR,BasriC,AriasMS,PrihatiniS,RintiswatiN,VoskensJ,
KimerlingME:HospitalDOTSlinkageinIndonesia:amodelforDOTS
expansionintogovernmentandprivatehospitals.InternationalJournalof
Conclusion
TuberculosisandLungDisease2007,11(1):33-39.
The process of integration identifies similarities and dif- 9. ProbandariA,LindholmL,StenlundH,UtariniA,HurtigA-K:Missed
ferences between sites in more affluent East China and opportunityforstandardizeddiagnosisandtreatmentamongadult
TuberculosispatientsinhospitalsinvolvedinPublic-PrivateMixfor
poorer West China. Integration of TB services in the
DirectlyObservedTreatmentShort-CoursestrategyinIndonesia:across-
hospitals needs to address the challenges of stakeholder sectionalstudy.BMCHealthServicesResearch2010,10(1):113.
motivations and resource allocation. Effective inter-orga- 10. ProbandariA,UtariniA,HurtigA-K:AchievingqualityintheDirectly
ObservedTreatmentShort-course(DOTS)strategyimplementation
nizational collaboration could help to improve the effi-
process:achallengeforhospitalPublic-PrivateMixinIndonesia.Global
ciency and quality of TB control. HealthAction2008,1(inclSupplements).
11. ProbandariA,UtariniA,LindholmL,HurtigA-K:Lifeofapartnership:The
processofcollaborationbetweentheNationalTuberculosisProgramme
andthehospitalsinYogyakarta,Indonesia.SocialScience&Medicine2011,
Acknowledgements
73(9):1386-1394.
ThisstudywassupportedbytheCommunicableDiseaseResearch
12. WangD,LiuJ,ChinD:Progressintuberculosiscontrolandtheevolving
Consortium(COMDIS)oftheDepartmentforInternationalDevelopmentof
public-healthsysteminChina.Lancet2007,369:691-696.
theUKGovernment;however,theviewsexpressedinthisarticlearethose
13. WangL,LiuX,HuangF,HennigC,UplekarM,JiangS:Engaginghospitals
oftheauthorsanddonotnecessarilyreflecttheopinionsofthesponsor.
tomeettuberculosiscontroltargetsinChina:usingtheInternetasa
TheauthorswishtothankcolleaguesfromGuangxiCDC,GuangxiNanning
tooltoputpolicyintopractice.BulletinofWorldHealthOrganization2010,
CDC,ShanghaiChangningCDCfortheireffortsintheproject
88(12):937-942.
implementationanddatacollection.Wealsothankalltheintervieweesfor 14. LiuY:China’spublichealth-caresystem:facingthechallenges.Bulletinof
theirparticipationinthestudy.WethankProfessorRobbieFoyofthe
theWorldHealthOrganisation2004,82(7):532-538.
AcademicUnitofPrimaryCare,UniversityofLeeds,andthetworeviewers
15. MengQ,LiR,ChengG,BlasE:ProvisionandfinancialburdenofTB
ofBMCHealthServicesResearchfortheircriticalcomments.Wealsothank
servicesinafinanciallydecentralizedsystem:acasestudyfrom
DrMeravKlineroftheNuffieldCentreforInternationalHealthand
Shandong,China.InternationalJournalofHealthPlanning&Management
Development,UniversityofLeedsforeditingofthemanuscripts.
2004,19(Suppl1):S45-62.
16. TangS,SquireS:Whatlessonscanbedrawnfromtuberculosiscontrolin
Authordetails Chinainthe1990’s?Ananalysisfromahealthsystemperspective.
1NuffieldCentreforInternationalHealthandDevelopment,Universityof
HealthPolicy2005,72:93-104.
Leeds(basedinChina),Room1220,No.1032DongmenNorthRd,Luohu
17. MoH:Reportonnationwiderandomsurveyfortheepidemiologyof
District,Shenzhen,518003,China.2TheChineseUniversityofHongKong,2/ tuberculosisin2000.Beijing,China:MinistryofHealthofthePeople’s
F,SchoolofPublicHealthandPrimaryCare,PrinceofWalesHospital,Shatin,
RepublicofChina;2002.
N.T.,HongKong,China.3NuffieldCentreforInternationalHealthand
18. YanF,ThomsonR,TangS,SquireS,WangW,LiuX,GongY,ZhaoF,
Development,UniversityofLeeds,101ClarendonRd,Leeds,LS29LJ,UK.
TolhurstR:Multipleperspectivesondiagnosisdelayfortuberculosis
4CenterforHealthManagementandPolicy,ShandongUniversity,China,
fromkeystakeholdersinpoorruralChina:casestudyinfourprovinces.
Mailbox128,No44WenhuaRd,Jinan,Shandong,250012,China.
HealthPolicy2007,82(2):186-199.
Authors’contributions 19. NCTB:GuidelineforthedeveopingtheTBdesignatedhospitalst(Global
FundRoundVIII).NCTP(2009)Guidelineforthedesignatedhospital
GZ,XW,JW,QSandJYwereinvolvedinconceptionanddesignofthis
development(GlobalFundRoundVIII)GFCOffice,TheGlobalFundChina
project,whileGZ,XW,QSandJYwereinvolvedwiththeimplementationof
office/NationalCentreforTBControlNationalCentreforTBControl;2009.
theprojectandanalysisandinterpretationofthedata.GZandXWhave
20. WeiX,LiangX,LiuF,WalleyJD,DongB:Decentralisingtuberculosis
draftedthemanuscriptswhileJWandQShaveprovidedcriticalcomments.
servicesfromcountytuberculosisdispensariestotownshiphospitalsin
Allauthorsreadandapprovedthefinalmanuscript.
China:aninterventionstudy.InternationalJournalofTuberculosisandLung
Disease2008,12(5):538-547.
Competinginterests
21. WeiXL,LiangXY,WalleyJD,LiuFY,DongBQ:Analysisofcare-seeking
Theauthorsdeclarethattheyhavenocompetinginterests.
pathwaysoftuberculosispatientsinGuangxi,China,withandwithout
decentralisedtuberculosisservices.InternationalJournalofTuberculosis
Received:5August2011 Accepted:25January2012
andLungDisease2009,13(4):514-520.
Published:25January2012
