Characteristics of study population
The respondents were grouped by sex, age, job status, education, income and whether or not they suffered illness in the two weeks prior to being surveyed. 41.55% were men and 41.81% were above 60 years of age. 45.04% were employed, 42.28% were retired and the rest were students or unemployed. The education distribution showed that 40.91% of those interviewed had elementary or less education (nine years or less), 29.91% had secondary education (twelve years) and 29.18% had a post-secondary education (more than fifteen years). To explain the socio-economic group differences, the sample was divided into four income groups according to their annual income: less than US$ 1,500 (22.75%), US$ 1,500-6,000 (55.58%), US$ 6,000-20,000 (18.67%) and more than US$20,000 (3%).
The age of the respondents was significantly correlated with job status ( ρ =0.61, p<0.001) and education level ( ρ =0.45, p<0.001). Significant correlation was also found between education and income level ( ρ =0.43, p<0.001); education and job status ( ρ =0.39, p<0.001); and between job status and income level ( ρ =0.32, p<0.001). Of the respondents, 1279 or 41.69% suffered illness in the previous two weeks to being surveyed.
Our sample represents the population who see a doctor in community health service center.
Satisfaction with different services and facilities
Residents’ satisfaction measurement was divided into five dimensions (clinical service, public health service, drug delivery system, health insurance system and overall satisfaction). Table shows the items and corresponding score of each dimension.
Main areas covered by the satisfaction scale
Demographic characteristic of respondents in Shanghai, 2011
As seen in Table , after calculated the average scores of the subareas for each of the four categories, we found that the residents were generally satisfied to a relatively high degree with the clinical service, the next highest level was with the public health service; and the results showed less satisfaction with the essential drug system and the health insurance system. The highest satisfaction was with staff attitude (3.98±0.69), and the next highest was with communication between physician and patient (3.90±0.70) and the medical environment (3.86±0.69). Residents were least satisfied with the drug prices (3.21±0.94), accessibility to drugs (3.27±0.68), convenience of reimbursement (i.e. paid by the insurance or the government) (3.29±0.83) and ratio of reimbursement (3.30±0.80). The overall satisfaction related to the health care system was just above the median score 3 (3.23±0.86).
Services satisfaction by different residents
Satisfaction scores for different dimensions and groups are shown in Table . The individual item satisfaction scores were aggregated into total mean scores for each of the four dimensions. The mean score for each dimension was analyzed by sex, age, place of birth, work status, education and income. Judged by different dimension scores, the results show that residents were less satisfied with the essential drug system and the health insurance system relative to the systems related to clinical and public health services/interventions. Scores were 3.20, 3.23, 3.79 and 3.62 respectively. The unemployed, those earning low incomes, born in a suburban setting and having received an elementary education or less, were found to have relatively low satisfaction with all four dimensions of the health care system. Residents who were women, aged over 60, retired, born in urban settings, and in the third-quarter income level (US$ 6,000-20,000), were more satisfied with the medical services. Residents who were women, aged over 60, retired, born in urban settings, received a secondary education and at the second quarter income level (US$ 1,500-6,000) were more satisfied with the public health services/interventions. Residents, who were men, aged under 60, born in rural settings, possessing an elementary or less education and at the third quarter income level were more satisfied with the essential drug system. Residents, who were under 60 years of age, workers not originally from Shanghai, employed, possessing a secondary education and at the third quarter income level were more satisfied with the health insurance system. The difference in the overall satisfaction score between groups was smaller, as shown in the last column of Table . On all scales, the community health care system earned mean scores of 3.20. The score was marginally above the midpoint (a score below 3 would indicate a negative evaluation).
Comparison of satisfaction between dimensions and groups
Factors associated with the residents’ perceptions of service improvement
The study further investigated the residents’ perceptions to the health service improvement. Out of all the respondents, 47.64% believed their access to drugs to have either not changed or decreased. Only one-third believed that it had changed for the better, and 19.81% considered it difficult to estimate. In terms of health insurance coverage, more than 53% of respondents thought that little had changed; more than 8% of respondents believed that the reimbursement rate had lowered; only 15.37% of respondents thought that the rate had increased, and 22.86% thought it was difficult to determine.
Residents’ perception with out-of-pocket expenditures and medicine prices was even lower. The percentage of respondents who thought they changed for the worse in these two aspects were 25.39% and 38.49%, respectively; 37.66% and 27.89% of respondents thought that there were no significant changes; only 17.14% and 14.82% felt that they changed for the better; and 19.81% and 18.80% thought the determination was difficult to make. Thus, compared with the price of medicines and the ratio of reimbursement, people have a relative high assessment on the medical environment, medical level and staff attitude; more than half the interviewers reported positive response. This result is thought to have arisen because the patients pay for the services mostly on a fee-for-service basis, so there was no incentive for the health service provider to control the costs. Although the government took some measures to control medicine and service prices, the result was still unsatisfactory according to the survey results. 60.61% of the retired and 49.49% of the unemployed reported negative response to the essential drug system. Indeed, even for the employed respondents, the degree of perception improvement with the essential drug delivery system was obviously lower than with other items. The details are shown in Table .
Respondents’ perceptions to the change of the health service improvement
Relationship between satisfaction and resident characteristics
The mean score for each dimension was analyzed by sex, age, place of residence, work status, education and income. From the results of the logistic regression models, being male, over age 50, from a rural setting, being retired, having an elementary education and having a low level of income were found to have an independent negative effect on every dimension of the health service system (P<0.01). There were significant positive effects (P<0.01) for local farmers, migrant workers, those with higher education level and high income. In particular, the migrant worker group reported greater satisfaction because they generally have graduated from university and can find stable jobs in cities. The results show that vulnerable groups have less accessibility to community health services, highlighting the need for more attention to be paid to this area during the reform process. The analysis results are shown in Table .
Satisfaction with the four dimensions of the health service system and with the overall evaluation, by background variables (logistic regression)
Results of the open ended question
In order to understand the satisfaction with community health services comprehensively, the questionnaire designed an open ended question. Compared with the beginning of the reform, the biggest difference is the improvement in terms of convenience, medical environment and staff attitude. Most of the questions focused on access to drugs, the reimbursement rate, out of pocket payment rate and medicine price.