Understanding prescribing behaviour of Tuberculosis doctors in the context of integrated service delivery: a case study of two designated hospitals of Zhejiang province, China
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There is on-going debate regarding if and how integrated service delivery might affect quality of care for infectious diseases traditionally delivered through vertical programmes. In China, tuberculosis (TB) care has recently been integrated into ‘designated’ public hospitals at the county level. However, the integration initiative has caused concerns among hospital providers about cost recovery for poorly funded public hospitals. These concerns are partially reflected in the prescription of non-standardized, non-free auxiliary treatment for TB patients, which increases patients’ financial burden and compromises quality of care. This study applies Complex Adaptive Systems (CAS) thinking to understand providers’ prescribing behaviour in the context of integrated service delivery in TB designated hospitals in Zhejiang province, China. A case study approach was applied to research conducted in two designated hospitals, where the TB clinic was subsidized through local government or the hospital respectively. This study started with a retrospective review of 340 medical charts of uncomplicated TB patients. Informed by the results of this review, 47 semi-structured interviews were conducted with health officials, public health officers, and hospital staff members such as managers and TB clinicians, radiologists, laboratory staff and nurses. The working environment of the TB health workers was also observed. A thematic approach was used to formulate the initial coding frame, as guided by the conceptual framework. Hospital-based integrated TB care is highly medicalised due to strong medical culture and values associated with the integrated care. In both hospitals, non-standardised, non-free prescription of drugs and interventions for uncomplicated TB is common, with no consistent patterns for the two hospitals. This can also be attributed to lack of clear guidelines, weak doctor-patient relationship and hidden financial incentives of TB doctors. Staff motivation is low due to the perceived poor opportunities for professional development in TB work, the perceived gap in salaries as compared to other clinical staff, and the limited provision of risk protection measures for TB health workers. Welfare of TB health workers, who generate limited income for hospitals, is accorded low priority. Professional differences and tension between public health and medical professionals remain the biggest barrier to ensuring clinical governance for TB control in the hospitals. This study suggests that non-standardised prescribing behaviour is a dynamic response to the systemic conditions generated by the current model of integrated service delivery in the designated hospitals in China. Delivering free and standardised integrated TB care in the designated hospitals is challenging in the context of highly fragmented disease control and clinical structures and market-orientated health services. Using CAS thinking has helped to shift attention from a functional analysis of the health systems ‘building blocks’ and their mechanical interactions towards a more dynamic way of examining emergence, feedback loops, adaptation and relationship management in the study of integrating a public health function (TB care) within a hospital setting. The study will inform the on-going discussion of strengthening the quality of integrated service delivery model in China and public-private mix for TB control in other similar contexts.