Equity and efficiency of health resource allocation in Sichuan Province, China

Abstract

Background

To analyze the equity and efficiency of health resource allocation in Sichuan Province and to provide a scientific basis for promoting health resource development.

Methods

Theil index, coefficient of variation, equalization index and health resource agglomeration degree (HRAD) were used to analyze the equity of health resource allocation, and data envelopment analysis (DEA) was used to analyze the efficiency of health resource allocation in Sichuan Province from 2017 to 2021.

Results

The Theil index and coefficient of variation of health technicians, licensed (assistant) physicians and registered nurses are larger than those of the number of beds, indicating that the equalization of the number of beds is relatively good. The equalization index of health resources in Sichuan Province ranges from 3.228 2 to 3.404 4 between 2017 and 2021, showing a gradually decreasing trend. The equalization index of Northwest Sichuan Economic Zone is the largest, indicating that the equity is relatively good. The equalization index of Chengdu Plain Economic Zone is the lowest, indicating that the equity is relatively poor. The HRAD of the number of beds, health technicians, licensed (assistant) physicians and registered nurses in Chengdu Plain Economic Zone, South Sichuan Economic Zone and Northeast Sichuan Economic Zone are all greater than 1, indicating that the health resources in these regions are better allocated by geography. The HRAD/ population agglomeration degree (PAD) of health technicians, licensed (assistant) physicians and registered nurses in South Sichuan Economic Zone, Northeast Sichuan Economic Zone and Panxi Economic Zone is less than 1, indicating that the health resources in these regions are insufficient relative to the agglomerated population. The comprehensive efficiency of health resource allocation in Sichuan Province and the five economic zones in 2020 is not 1, and the DEA is relatively ineffective. The Panxi Economic Zone, Northeast Sichuan Economic Zone and Northwest Sichuan Economic Zone all have relatively ineffective DEA.

Conclusions

From 2017 to 2021, health resources in Sichuan Province continue to grow, but equity has gotten worse. The degree of variation in the health resource allocation among the five major economic zones in Sichuan Province is large, with the Chengdu Plain Economic Zone having better equity in the health resource allocation by population and geography, and the Panxi Economic Zone and the Northwest Sichuan Economic Zone having insufficient equity in the health resource allocation by population and geography. The efficiency of health resource allocation in the Panxi Economic Zone, Northeast Sichuan Economic Zone and Northwest Sichuan Economic Zone needs to be improved.

Background

Health resources refer to the combination of production factors used and consumed by the society in the process of providing medical and health services, and are an important indicator to measure the health status of a region, as well as an important factor to ensure the enjoyment of health by the population [1]. Health resources are limited [2], so it is necessary to optimize the allocation of health resources in combination with the natural environment, the level of social and economic development, the health status of the population and other factors, and to promote the equity and efficiency of health resource allocation [3], so as to give full play to the role of health resources as far as possible.

The Notice of the "Fourteenth Five-Year Plan" Health Development Plan of Sichuan Province (CBF [2021] No. 65) requires adherence to balanced accessibility, promotion of the equalization of basic public health services, and gradual reduction of the disparities in basic health services between urban and rural areas, regions, and populations, so as to promote health equity. Sichuan Province has always attached great importance to the development of health care and has continuously taken various measures to promote the allocation of health resources, improve the level of medical services [4], and create better conditions for building a health highland in western China. However, the problem of insufficient and unbalanced development of health care in Sichuan Province still exists, with weak grassroots service capacity and unbalanced development of health care in the five major economic zones [5]. In order to promote health equity, Sichuan Province should pay more attention to how to allocate health resources in a scientific and reasonable way, and improve the equity and efficiency of health resource allocation [6].

At present, research on health resource allocation can be divided into the following three aspects. First, research methods such as the Gini coefficient and the Theil index are used to study the equity of health resource allocation, mainly including the equity of public health resources [7], the equity of resource allocation in the rural three-tier health system [8], and the equity of mental health bed distribution in China [9]. Second, the data envelopment analysis (DEA) series methods are used to study the efficiency of health resource allocation, mainly including the efficiency of medical service resources in China [10], the efficiency of essential public health services in Hainan Province [11], and the efficiency of the primary health care system resources [12]. Third, research methods such as Grey Model GM (1,1) and ARIMA model are used to predict health resources, mainly including the prediction of efficiency differences in Chinese provincial community health services [13], the prediction of bed allocation of stomatology department in Chinese hospitals [14], and the match level and prediction of aging and medical resources in China [15]. The existing researches on health resource allocation in Sichuan Province have less often used the equalization index based on the Theil index and coefficient of variation for analysis, and less often explored the imbalance of health resource allocation in the five major economic zones of Sichuan Province. In this study, the Theil index, coefficient of variation, equalization index and health resource agglomeration degree (HRAD) are used to analyze the equity of health resource allocation in Sichuan Province from 2017 to 2021, and DEA is used to analyze the efficiency of health resource allocation in Sichuan Province from 2017 to 2021, so as to provide scientific basis for promoting the development of health resources in Sichuan Province.

Methods

Data sources

Data on health resources in Sichuan Province were obtained from the Sichuan Health Statistical Yearbook for 2017–2021 (https://wsjkw.sc.gov.cn/scwsjkw/njgb/tygl.shtml), and the number of residents population and geographic areas were obtained from the Sichuan Statistical Yearbook for 2018–2022 (http://tjj.sc.gov.cn/scstjj/c105855/nj.shtml).

Theil index

The Theil index is used to measure the overall equity of health resource allocation [16]. The value of the Theil index is calculated from the proportion of the number of resident population in each component and the corresponding proportion of health resources [17]. The smaller the Theil index, the better the equity [18]. The formula is:

$$\text{T}=\sum _{\text{i}=1}^{\text{n}}{\text{P}}_{\text{i}}\text{log}\frac{{\text{P}}_{\text{i}}}{{\text{Y}}_{\text{i}}}$$

where, n represents the number of regions, Pi represents the proportion of the number of resident population in the ith region to the total resident population, and Yi represents the proportion of health resources in the ith region to the total health resources.

Coefficient of variation

The coefficient of variation is used to measure the dispersion of each component and can be expressed as the ratio of the standard deviation of each component to the average value [19]. A higher coefficient of variation indicates a higher degree of dispersion and a lower degree of equity in the allocation of health resources among the components. The formula is:

$${\text{E}}_{\text{i}}=\frac{{\text{S}}_{\text{i}}}{{\overline{\text{Y}}}_{\text{i}}}$$

where, Ei is the coefficient of variation of health resources in each region in the ith year, Si is the standard deviation of health resources in each region in the ith year, and ‾Yi is the average value of health resources in each region in the ith year.

Equalization index

The Theil index and coefficient of variation of the four indicators are each given the same weight (25%) respectively and then weighted average, so as to calculate the comprehensive Theil index and coefficient of variation. The larger the value of comprehensive Theil index and coefficient of variation, the more unbalanced the distribution of health resources and the lower the equity. The equalization index is the reciprocal of the sum of the comprehensive Theil index and coefficient of variation. The larger the equalization index, the better the equity. The formula is:

$${\text{I}}_{\text{i}}=\frac{1}{{\overline{\text{T}}}_{\text{i}}+{\overline{\text{E}}}_{\text{i}}}$$

where, Ii is the equalization index of the ith year, and ‾Ti and ‾Ei are the weighted average values of the Theil index and coefficient of variation of health resources in the ith year respectively.

Health resource agglomeration degree(HRAD)

The HRAD is usually used in combination with the population agglomeration degree(PAD). The HRAD is the proportion of health resources gathered on 1% of the total land area of a region, and the PAD is the proportion of the population gathered on 1% of the total land area of a region.HRAD greater than 1 indicates that health resources are well allocated by geography, and less than 1 indicates that health resources are inadequately allocated by geography [20].HRAD/PAD greater than 1 indicates that health resources are surplus relative to the agglomeration population, and less than 1 indicates that health resources are insufficient relative to the agglomeration population [21]. The formula is:

$${\text{HRAD}}_{\text{i}}=\frac{(\frac{{\text{HR}}_{\text{i}}}{{\text{HR}}_{\text{n}}})\times 100\%}{(\frac{{\text{A}}_{\text{i}}}{{\text{A}}_{\text{n}}})\times 100\%}$$

where, HRi is the number of health resources in region i, HRn is the number of health resources in the whole region, Ai is the geographical area of region i, and An is the geographical area of the whole region. PAD is calculated by replacing the number of health resources with the number of resident population.

Data envelopment analysis (DEA)

DEA is a method that can be used to evaluate the relative efficiency of multi input and multi output measurement decision making units (DMUs) [22]. It is widely used in the medical and health field [23]. In DEA, BCC model assumes variable returns to scale, decomposes the comprehensive efficiency into the product of technical efficiency and scale efficiency, and obtains returns to scale and relative effectiveness among decision-making units. The DEA is relatively effective if the comprehensive efficiency value is equal to 1, and the DEA is invalid if the comprehensive efficiency value is less than 1. The lower the value, the lower the relative efficiency. In this study, Excel 2010 is used to input data, DEAP 2.1 is used to calculate, and DEA-BCC model is used to calculate the relative efficiency.

Setting

According to the new development pattern of "One Trunk, Multiple Branches, Five Regions Synergy" in Sichuan Province, Sichuan Province is divided into Chengdu Plain Economic Zone (CPEZ), South Sichuan Economic Zone (SSEZ), Northeast Sichuan Economic Zone (NESEZ), Panxi Economic Zone (PEZ) and Northwest Sichuan Economic Zone (NWSEZ). Chengdu Plain Economic Zone includes the 8 regions of Chengdu, Mianyang, Deyang, Meishan, Leshan, Suining, Ziyang and Ya'an. South Sichuan Economic Zone includes the 4 regions of Luzhou, Zigong, Neijiang and Yibin. Northeast Sichuan Economic Zone includes the 5 regions of Guangyuan, Nanchong, Guang'an, Dazhou and Bazhong. Panxi Economic Zone includes the 2 regions of Liangshan and Panzhihua. Northwest Sichuan Economic Zone includes the 2 regions of Aba and Ganzi (Fig. 1).

Fig. 1.

The distribution of five Economic Zone in Sichuan Province. The base map is derived from the National Natural Resources and Geospatial Basic Information Database of PRC (https://www.sgic.net.cn/portal/index.html#/Home), review number GS(2024)0650, and these shapes are licensed without need for permission

Indicators and measurement tools

The number of beds, health technicians, licensed (assistant) physicians and registered nurses were selected as the indicators to evaluate the equity of health resource allocation. When evaluating the efficiency of health resource allocation, the input indicators were the above four indicators, and the output indicators were three indicators, including the total number of diagnosis and treatments, the number of hospital admissions, and the number of surgeries [24]. Theil index, coefficient of variation, equalization index and HRAD were used to analyze the equity of health resource allocation in Sichuan Province, and DEA was used to analyze the efficiency of health resource allocation in Sichuan Province.

Results

Health resource and service utilization per 1000 population

The allocation of health resources in Sichuan Province continues to grow. The number of beds, health technicians, licensed (assistant) physicians and registered nurses per 1000 population increases from 6.80, 6.41, 2.36, and 2.76 in 2017 to 7.91, 8.04, 2.99, and 3.66 in 2021, respectively. The total number of diagnosis and treatments and hospital admissions in Sichuan Province shows a trend of first increasing, then decreasing and then increasing, and the number of surgical continues to increase. The total number of diagnosis and treatment, hospital admission and surgical per 1000 population increases from 5,855.42, 220.05, and 43.14 in 2017 to 6,527.40, 222.52, and 69.81 in 2021, respectively (Table 1).

Table 1.

Health resource and service utilization per 1000 population

Year	Number of beds	Health technicians	Licensed (assistant) physicians	Registered nurses	Total number of diagnosis and treatment visits	Number of hospital admissions	Number of surgical personnel
2017	6.80	6.41	2.36	2.76	5 855.42	220.05	43.14
2018	7.20	6.77	2.47	2.97	6 201.90	220.45	48.59
2019	7.56	7.22	2.66	3.24	6 708.89	237.25	57.76
2020	7.76	7.57	2.81	3.42	6 122.04	209.78	58.37
2021	7.91	8.04	2.99	3.66	6 527.40	222.52	69.81

Theil index and coefficient of variation of health resources

The Theil index and coefficient of variation of health technicians, licensed (assistant) physicians, and registered nurses are higher than those of the number of beds, indicating that the equity of the number of beds is relatively good. The Theil index and coefficient of variation of registered nurses are the largest, indicating that the equity of registered nurses is the worst. From 2017 to 2021, the Theil index of health technicians, licensed (assistant) physicians and registered nurses show an overall decreasing trend, indicating that the equity of these health resources is gradually getting better. From 2017 to 2021, the coefficient of variation of health technicians, licensed (assistant) physicians and registered nurses showed an overall increasing trend, indicating that the degree of variation of these health resources has increased (Table 2).

Table 2.

Theil index and coefficient of variation of health resources

Year	Number of beds		Health technicians		Licensed (assistant) physicians		Registered nurses
	Theil index	Coefficient of variation	Theil index	Coefficient of variation	Theil index	Coefficient of variation	Theil index	Coefficient of variation
2017	0.003 2	0.956 6	0.008 1	1.205 8	0.009 7	1.208 6	0.012 5	1.295 2
2018	0.003 1	0.958 4	0.007 6	1.215 8	0.009 1	1.220 0	0.011 2	1.297 6
2019	0.003 5	0.944 3	0.007 3	1.248 3	0.009 0	1.257 8	0.010 7	1.332 7
2020	0.003 1	0.949 0	0.006 4	1.255 7	0.007 8	1.254 3	0.009 2	1.335 2
2021	0.003 0	0.979 4	0.006 3	1.290 6	0.007 5	1.308 7	0.008 6	1.352 1

Equalization index of health resources

From 2017 to 2021, the comprehensive Theil index of health resources in Sichuan Province ranged from 0.001 6 to 0.002 1, the comprehensive coefficient of variation ranged from 0.291 6 to 0.308 2, and the equalization index ranged from 3.228 2 to 3.404 4. The equalization index of health resources in Sichuan Province showed a decreasing trend, indicating that the equity is gradually getting worse (Fig. 2).

Fig. 2.

Equalization index of health resources

Theil index and coefficient of variation of five economic zones

The degree of variation in health resource allocation in the five economic zones of Sichuan Province is large. The Theil index of the number of beds, health technicians, licensed (assistant) physicians and registered nurses is the smallest in SSEZ, indicating that the equity of health resource allocation is better in SSEZ. The Theil index of the number of beds, health technicians and licensed (assistant) physicians is the largest in PEZ, indicating that the equity of health resources allocation is poor in Panzhihua Xichang Economic Zone. The coefficient of variation of the number of beds, health technicians, licensed (assistant) physicians and registered nurses is the largest in the CPEZ, indicating that the degree of variation in health resource allocation was higher in the CPEZ. The coefficient of variation of the number of beds, health technicians and registered nurses are the smallest in the NWSEZ, indicating that the equity of the three health resources allocation is better in NWSEZ (Table 3).

Table 3.

Theil index and coefficient of variation of five economic zones

Year	Zones	Number of beds		Health technicians		Licensed (assistant) physicians		Registered nurses
		Theil index	Coefficient of variation	Theil index	Coefficient of variation	Theil index	Coefficient of variation	Theil index	Coefficient of variation
2017	CPEZ	0.000 8	1.065 9	0.005 1	1.282 0	0.004 2	1.259 3	0.008 1	1.340 4
	SSEZ	0.000 4	0.187 2	0.001 3	0.170 5	0.001 6	0.130 9	0.001 6	0.189 9
	NESEZ	0.005 2	0.323 6	0.004 2	0.326 1	0.005 6	0.354 4	0.003 6	0.321 2
	PEZ	0.005 9	0.451 3	0.011 8	0.386 9	0.022 9	0.297 1	0.014 1	0.365 9
	NWSEZ	0.001 7	0.042 5	0.003 3	0.007 3	0.012 3	0.106 9	0.006 3	0.039 7
2018	CPEZ	0.000 8	1.075 8	0.004 7	1.294 9	0.003 6	1.265 1	0.007 5	1.355 3
	SSEZ	0.000 6	0.175 3	0.001 2	0.178 1	0.001 5	0.142 6	0.001 2	0.192 2
	NESEZ	0.004 5	0.303 7	0.005 3	0.324 3	0.006 1	0.364 1	0.004 6	0.311 2
	PEZ	0.006 3	0.449 0	0.010 4	0.403 3	0.019 4	0.326 4	0.013 1	0.377 7
	NWSEZ	0.002 4	0.030 5	0.004 8	0.012 6	0.012 8	0.106 0	0.005 4	0.020 6
2019	CPEZ	0.001 1	1.064 6	0.004 9	1.321 8	0.003 9	1.297 7	0.007 8	1.384 1
	SSEZ	0.001 0	0.170 8	0.001 3	0.185 6	0.002 0	0.160 1	0.001 1	0.200 7
	NESEZ	0.004 5	0.298 8	0.004 8	0.309 5	0.005 2	0.340 0	0.003 9	0.311 1
	PEZ	0.005 8	0.458 2	0.007 8	0.434 1	0.017 0	0.348 3	0.009 5	0.416 5
	NWSEZ	0.003 0	0.024 8	0.005 2	0.011 7	0.012 8	0.100 4	0.005 8	0.020 3
2020	CPEZ	0.001 4	1.070 2	0.004 2	1.328 7	0.003 3	1.302 6	0.006 8	1.390 2
	SSEZ	0.000 9	0.179 8	0.001 0	0.196 0	0.001 8	0.163 3	0.000 9	0.224 0
	NESEZ	0.003 4	0.317 8	0.004 6	0.301 7	0.005 0	0.333 8	0.003 8	0.309 7
	PEZ	0.004 5	0.477 1	0.006 1	0.455 6	0.012 8	0.384 9	0.007 6	0.438 0
	NWSEZ	0.003 5	0.020 5	0.004 5	0.004 5	0.010 1	0.067 9	0.004 5	0.004 3
2021	CPEZ	0.001 5	1.091 1	0.004 7	1.357 3	0.004 1	1.347 9	0.006 7	1.401 1
	SSEZ	0.000 8	0.184 8	0.000 8	0.203 0	0.001 2	0.181 5	0.000 5	0.219 0
	NESEZ	0.002 4	0.352 1	0.003 3	0.327 6	0.003 2	0.358 2	0.002 6	0.338 2
	PEZ	0.004 5	0.478 4	0.005 9	0.458 9	0.010 9	0.404 0	0.006 2	0.455 0
	NWSEZ	0.003 7	0.020 2	0.003 9	0.015 4	0.009 9	0.063 0	0.004 4	0.006 9

CPEZ Chengdu Plain Economic Zone, SSEZ South Sichuan Economic Zone, NESEZ Northeast Sichuan Economic Zone, PEZ Panxi Economic Zone, NWSEZ Northwest Sichuan Economic Zone

Equalization index of five economic zones

The degree of variation in health resources in the five economic Zones of Sichuan Province is large. From 2017 to 2021, the equalization index of CPEZ ranges from 3.07 to 3.20, the equalization index of SSEZ ranges from 20.21 to 23.39, the equalization index of NESEZ ranges from 11.53 to 12.60, the equalization index of PEZ ranges from 8.77 to 10.29, and the equalization index of NWSEZ ranges from 73.99 to 133.82. The equalization index of NWSEZ is the largest, indicating that the equity is relatively good, followed by SSEZ, and CPEZ has the smallest equalization index, indicating that the equity is relatively poor. The equalization index of SSEZ and PEZ shows a decreasing trend, indicating that the equity of these two zones is getting worse. The equalization index of NWSEZ shows an overall increasing trend, indicating that the equity of NWSEZ is gradually getting better (Fig. 3).

Fig. 3.

Equalization index of five economic zones. CPEZ Chengdu Plain Economic Zone, SSEZ South Sichuan Economic Zone, NESEZ Northeast Sichuan Economic Zone, PEZ Panxi Economic Zone, NWSEZ Northwest Sichuan Economic Zone

HRAD of five economic zones

From the perspective of HRAD, the number of beds, health technicians, licensed (assistant) physicians and registered nurses in the CPEZ, SSEZ and NESEZ are all greater than 1, indicating that the health resources in these regions are better allocated by geography. The number of beds, health technicians, licensed (assistant) physicians and registered nurses in the PEZ and NWSEZ are all less than 1, indicating that the health resources in these regions are insufficient by geography.

From the perspective of HRAD/PAD, the number of beds, health technicians, licensed (assistant) physicians and registered nurses in the CPEZ is greater than 1, indicating that the health resources in the CPEZ are excess relative to the agglomeration population. The number of beds in the PEZ and NWSEZ is less than 1, health technicians, licensed (assistant) physicians and registered nurses in the SSEZ, NESEZ and PEZ is less than 1, indicating that the health resources in these regions are insufficient relative to the agglomeration population (Table 4).

Table 4.

HRAD of five economic zones

Year	Zones	PAD	HRAD				HRAD/PAD
			Number of beds	Health technicians	Licensed (assistant) physicians	Registered nurses	Number of beds	Health technicians	Licensed (assistant) physicians	Registered nurses
2017	CPEZ	2.74	2.84	3.06	3.11	3.15	1.04	1.12	1.13	1.15
	SSEZ	2.44	2.55	2.33	2.28	2.42	1.04	0.96	0.94	0.99
	NESEZ	1.82	1.73	1.50	1.55	1.39	0.95	0.83	0.85	0.77
	PEZ	0.52	0.46	0.46	0.41	0.46	0.89	0.88	0.80	0.89
	NWSEZ	0.05	0.04	0.05	0.04	0.04	0.71	1.01	0.81	0.70
2018	CPEZ	2.77	2.83	3.06	3.12	3.12	1.02	1.11	1.13	1.13
	SSEZ	2.42	2.56	2.34	2.29	2.44	1.06	0.97	0.95	1.01
	NESEZ	1.79	1.75	1.51	1.55	1.42	0.98	0.84	0.86	0.79
	PEZ	0.52	0.45	0.46	0.41	0.46	0.87	0.87	0.78	0.88
	NWSEZ	0.05	0.04	0.05	0.04	0.03	0.72	1.00	0.78	0.70
2019	CPEZ	2.79	2.81	3.08	3.15	3.15	1.01	1.10	1.13	1.13
	SSEZ	2.40	2.61	2.33	2.28	2.41	1.09	0.97	0.95	1.00
	NESEZ	1.77	1.77	1.49	1.52	1.42	1.00	0.84	0.86	0.80
	PEZ	0.52	0.44	0.46	0.40	0.45	0.84	0.88	0.78	0.87
	NWSEZ	0.05	0.03	0.05	0.04	0.03	0.71	0.98	0.82	0.69
2020	CPEZ	2.82	2.80	3.09	3.13	3.14	1.00	1.10	1.11	1.11
	SSEZ	2.38	2.55	2.35	2.34	2.40	1.07	0.99	0.98	1.01
	NESEZ	1.75	1.80	1.48	1.50	1.42	1.03	0.85	0.86	0.81
	PEZ	0.52	0.44	0.45	0.40	0.46	0.84	0.87	0.77	0.88
	NWSEZ	0.05	0.04	0.05	0.04	0.03	0.73	0.97	0.88	0.71
2021	CPEZ	2.83	2.84	3.11	3.16	3.15	1.00	1.10	1.12	1.11
	SSEZ	2.38	2.52	2.30	2.24	2.37	1.06	0.97	0.94	1.00
	NESEZ	1.74	1.78	1.48	1.51	1.43	1.03	0.85	0.87	0.82
	PEZ	0.52	0.44	0.46	0.40	0.45	0.84	0.87	0.78	0.87
	NWSEZ	0.05	0.03	0.04	0.04	0.03	0.71	0.94	0.86	0.68

CPEZ Chengdu Plain Economic Zone, SSEZ South Sichuan Economic Zone, NESEZ Northeast Sichuan Economic Zone, PEZ Panxi Economic Zone, NWSEZ Northwest Sichuan Economic Zone, HRAD health resource agglomeration degree, PAD population agglomeration degree

Efficiency and relaxation of health resource

In 2017–2019 and 2021, the comprehensive efficiency, technical efficiency and scale efficiency of Sichuan Province are all 1, the returns to scale are constant, and the DEA is relatively effective, indicating that the invested health resources are fully utilized and reach the relative optimal scale state. In 2020, the comprehensive efficiency, technical efficiency and scale efficiency are not 1, the returns to scale are increasing, and the DEA is relatively ineffective, indicating that there are problems such as the unreasonable structure and underutilization of health resources allocation (Table 5).

Table 5.

Efficiency and relaxation of health resource

Year	Comprehensive efficiency	Technical efficiency	Scale efficiency	Returns to scale	Number of beds	Health technicians	Licensed (assistant) physicians	Registered nurses	Total number of diagnosis and treatments	Number of hospital admissions	Number of surgeries	Relative efficiency
2017	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
2018	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
2019	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
2020	0.928	0.964	0.962	Increasing	5 722.447	656.032	912.677	0.000	0.000	273 173.785	0.000	Inefficient
2021	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient

Efficiency and relaxation of health resource in five economic zones

Except for 2020, the comprehensive efficiency, technical efficiency and scale efficiency of the CPEZ and SSEZ are all 1, the returns to scale are constant, and the DEA is relatively efficient, indicating that the invested health resources are fully utilized and reach a relatively optimal scale state. In 2020, the comprehensive efficiency, technical efficiency and scale efficiency of the five economic zones in Sichuan Province are not 1, and the DEA is relatively ineffective, which may be caused by the impact of the COVID-19. The comprehensive efficiency, technical efficiency, and scale efficiency of the PEZ in 2018 are not 1, the returns to scale are increasing, and the DEA is relatively ineffective, indicating the existence of poorly allocated scale and inefficient utilization.The comprehensive efficiency of the NESEZ in 2018, and the NWSEZ in 2019 and 2021 are not 1, the returns to scale are decreasing, and the DEA is relatively ineffective, indicating that the health resources allocation structure is unreasonable (Table 6).

Table 6.

Efficiency and relaxation of health resource in five economic zones

Year	Zones	Comprehensive efficiency	Technical efficiency	Scale efficiency	Returns to scale	Number of beds	Health technicians	Licensed (assistant) physicians	Registered nurses	Total number of diagnosis and treatments	Number of hospital admissions	Number of surgeries	Relative efficiency
2017	CPEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	SSEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	NESEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	PEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	NWSEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
2018	CPEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	SSEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	NESEZ	0.992	0.992	1.000	Decreasing	2 191.975	1 300.884	0.000	1 087.092	0.000	142 485.162	0.000	Inefficient
	PEZ	0.963	0.991	0.972	Increasing	562.088	300.165	0.000	195.226	0.000	111 923.676	0.000	Inefficient
	NWSEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
2019	CPEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	SSEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	NESEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	PEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	NWSEZ	0.989	1.000	0.989	Decreasing	255.063	0.000	186.415	208.134	0.000	13 087.818	5 039.387	Inefficient
2020	CPEZ	0.921	0.966	0.953	Increasing	3 557.821	749.094	0.000	4.306	0.000	118 448.224	0.000	Inefficient
	SSEZ	0.956	0.973	0.982	Increasing	1 276.246	1 347.798	1 461.880	0.000	0.000	112 353.087	0.000	Inefficient
	NESEZ	0.943	0.961	0.982	Increasing	1 765.488	72.138	0.000	612.337	0.000	197 057.055	0.000	Inefficient
	PEZ	0.930	0.964	0.965	Increasing	0.000	430.883	128.609	592.114	751 227.784	0.000	0.000	Inefficient
	NWSEZ	0.900	0.902	0.997	Increasing	402.905	0.000	511.151	386.415	0.000	25 208.145	5 088.036	Inefficient
2021	CPEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	SSEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	NESEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	PEZ	1.000	1.000	1.000	Constant	0.000	0.000	0.000	0.000	0.000	0.000	0.000	Efficient
	NWSEZ	0.929	0.956	0.972	Decreasing	28.571	0.000	622.721	436.965	0.000	42 015.529	3 579.475	Inefficient

CPEZ Chengdu Plain Economic Zone, SSEZ South Sichuan Economic Zone, NESEZ Northeast Sichuan Economic Zone, PEZ Panxi Economic Zone, NWSEZ Northwest Sichuan Economic Zone

Discussion

Health resources in Sichuan Province continue to grow. The number of beds, health technicians, licensed (assistant) physicians and registered nurses per 1000 population is 6.1, 2.5 and 3.2, respectively, which is the development target for 2020 set by the 13th Five-Year Health and Family Planning Development Plan of Sichuan Province (CWF [2016] No. 127). The number of beds, licensed (assistant) physicians and registered nurses per 1000 population has reached 7.91, 2.99, and 3.66, respectively, in 2021, which has far exceeded the development target. This shows that Sichuan Province attaches great importance to the development of health care and continues to improve the allocation of health resources.

From the perspective of the comprehensive coefficient of variation and the equalization index, the quity of health resource allocation in Sichuan Province has deteriorated. We believe there are several reasons for this. On the one hand, Sichuan Province has a large geographical area, with many poor and remote mountainous areas and many minority areas. Health resources are mainly concentrated in the plain areas, resulting in large differences in health resource allocation. On the other hand, the agglomeration effect of population and economy is further emphasized [25]. The population and economy are concentrated in Chengdu and other regions, with convenient transportation and active social medical services, further promoting the development of the medical market [26], while the vast poor and remote mountain areas are sparsely populated, with poor health resources and service capabilities [27]. From the Theil index and the comprehensive Theil index, the equity of health resource allocation in Sichuan Province is gradually getting better, indicating that the Theil index measures the sensitivity of the differences between regions and that the differences in equity between regions are gradually decreasing. This is different from the equity measured by the coefficient of variation, which increases to indicate that the difference between the regions and the average level of Sichuan Province is gradually increasing, thus leading to a deterioration in the equity of health resources. Therefore, it is necessary to focus on the equity of health resource allocation, focus on the construction of health care system in areas with weak health resources [28], such as poor and remote areas, and reduce the coverage radius of coverage of grassroots health organizations, so as to further narrow the gap in health resource allocation. It is also necessary to strengthen counterpart support from regions with adequate health resources to regions with weak health resources, and to make full use of telemedicine and other information-based means to promote the vertical flow of health resources.

From the perspective of Theil index and coefficient of variation, compared with health technicians, licensed (assistant) physicians and registered nurses, the equity of the number of beds is better, which indicates that the equity of health physical resources is better than that of health human resources. This may be caused by the fact that health physical resources are more vulnerable to the impact of policy regulation, while health human resources are more vulnerable to the impact of the market. Health physical resources, such as beds, can be built in a short time through policy regulation, while health human resources, such as health technicians, are highly mobile, rely more on the regulatory role of the market, and it is difficult to directly affect equity through policy regulation. Health human resources are more likely to be affected by factors such as convenient transport, better pay and greater scope for career development [29], and are more likely to congregate in areas with good economic conditions [30]. Poor and remote areas are less attractive to health human resources, and health human resources are more likely to be lost to other areas with better conditions. The Theil index and coefficient of variation of registered nurses are the largest, which indicates that the equity of registered nurses is the worst, which may be related to the unclear responsibilities of nurses, heavy work tasks, and low social status. Therefore, it is necessary to formulate biased policies to increase support and incentives for health personnel in poor and remote areas in order to promote the introduction and retention of health personnel. It is necessary to strengthen the training of health personnel, and through the policy of targeted training in medical schools, to train local health technicians to supplement the shortage of health personnel [31]. It is also necessary to focus on the allocation of registered nurses, and to gradually strengthen the nursing team and mobilize the enthusiasm of health human resources by improving the title promotion channels for registered nurses, raising the level of remuneration and other measures [32].

From the perspective of equalization index and HRAD, the degree of variation in the health resources allocation in the five economic zones of Sichuan Province is large, which shows that the CPEZ has sufficient health resources but poor equity, and the NWSEZ has insufficient health resources but better equity. The CPEZ has a more developed economy, convenient transportation conditions, a well-developed medical market, and health resource allocation is adequate both by population and geography. However, the equalization index of the CPEZ shows poor equity, which may be due to the fact that health resources are more abundant in the central city and relatively insufficient in the rural and grassroots areas, especially the "siphoning effect" from the city to the rural areas, resulting in the concentration of health resources and services in the central city and the relative scarcity of health resources in the grassroots areas [33]. Health resources in the NWSEZ are inadequate both by population and geography. The NWSEZ has a large geographical area and an underdeveloped economy, which results in a relative shortage of health resources. The equalization index of the NWSEZ shows better equity, indicating a lower degree of variation in the distribution of health resources, but this is caused by the inadequacy of health resources. Therefore, the CPEZ should strengthen the policy support to the grassroots areas, promote the construction of standardized township health centers and village health offices in grassroots areas, and give full play to the health resources in grassroots areas. The NWSEZ should strengthen the health resource allocation, supplement the health resources in the insufficient areas according to the targets set in the health plan [34], and further improve the equity of health resource allocation on the basis of strengthening the health resource allocation, so as to meet the people's demand for medical care.

From the perspective of HRAD, the equity of health resource allocation by population and geography is insufficient in the PEZ and NWSEZ, while the equity of health resource allocation by geography is good in the SSEZ and NESEZ, but insufficient by population. The PEZ and NWSEZ have a large minority population, poor social and economic development, and high health care costs [35]. Therefore, the allocation of health resources in these two regions has been weak for a long time. Health resources are insufficient by population and geography, and it is difficult to meet people's basic medical needs. The SSEZ and NESEZ have a large population and convenient transportation, and health resource allocation is more equitable by geography, but it is insufficient in relation to the agglomeration population, and it is difficult for health resources to meet the medical needs of the agglomeration population. Therefore, each economic zone should take targeted measures to allocate health resources [36], and the PEZ and NWSEZ should actively introduce and train health technicians to supplement the medical team. At the same time, it should pay attention to the quity of health resources by geography, and to try to avoid that people do not seek medical care because of the large geographical radius [37]. The SSEZ and NESEZ should focus on optimizing the quality of health resources and improving the level and efficiency of medical services, and rationalizing the development of new types of treatment services, such as day surgery and Internet hospitals, in order to meet the medical needs of the agglomeration population.

The comprehensive efficiency of Sichuan Province and the five economic zones in 2020 is not 1, and the DEA is relatively ineffective, which may be caused by the impact of the COVID-19 that started in December 2019.In 2020, compared to 2019, health resources per 1,000 population in Sichuan Province have increased, but the total number of diagnosis and treatments per 1,000 population has declined by 586.85, and the number of hospital admissions per 1,000 population has declined by 27.48. The COVID-19 has had a large impact on the utilization of health services, and some people have chosen to reduce on-site medical services due to the limitations on consultation and treatment services imposed by the policy of preventing and controlling the COVID-19 [38]. Although online medical services and Internet hospital services have been supplemented in a timely manner, the total number of diagnoses and treatments and hospital admissions still declined significantly [39], resulting in an inefficient allocation of health resources in both Sichuan Province and the five economic zones in 2020. In 2021, the total number of diagnoses and treatments and hospital admissions gradually increased, the utilization of health services gradually increased, and the comprehensive efficiency of health resource allocation in Sichuan Province was 1, and the DEA was relatively effective, indicating that the health resources were fully utilized and reached a relatively optimal scale state.

From the perspective of allocation efficiency of the five economic zones, the comprehensive efficiency of the PEZ is not 1, DEA is relatively ineffective, and returns to scale are increasing, indicating that there are problems such as allocation inefficiency and poor scale. The PEZ has a large minority population, a large radius of health services, poor transportation infrastructure, and a consistently weak health resource allocation. Inadequate basic medical protection has led to inefficient allocation of health resources. The ethnic minorities have a relatively weak sense of medical care, which leads to the ineffective use of grass-roots medical and health services. With the support of medical insurance policy for medical treatment in other places, patients are more likely to be lost to nearby areas with higher levels of medical care, which leads to the idle state of the inherently weak health resources and further restricts the improvement of efficiency of health resource allocation. The comprehensive efficiency of the NESEZ in 2018, and the NWSEZ in 2019 and 2021 is not 1, the returns to scale are decreasing, and the DEA is relatively ineffective, indicating that the structure of health resource allocation is unreasonable. Hospitals in these regions blindly expand their construction to obtain better policy support and health insurance funding, leading to an irrational structure of health resource allocation. The regional distribution of health resources and medical services is uneven, with health resources and medical services concentrated in urban areas and a relative lack of them in poor, remote and grass-roots areas [40], leading to an irrational structure in the allocation of health resources, thereby affecting the overall efficiency of health resource allocation. Therefore, the PEZ, the NWSEZ and other regions should continue to increase the accessibility of health resource allocation, improve the construction of primary medical and health care service systems in poor and remote areas, and promote the effective use of health resources. It is important to strengthen the publicity and education of health care knowledge, continue to raise people's awareness of the need to see a doctor, and cultivate the local health care market in order to improve the overall efficiency of health resource allocation [41].

Although we used the Theil index, coefficient of variation, equalization index, HRAD, and DEA to evaluate the equity and efficiency of health resource allocation in Sichuan Province from 2017 to 2021, this study still has some limitations. First, the selection of evaluation indicators is based on previous relevant studies, and these are the evaluation indicators usually used in similar studies. Second, although we evaluated the equity and efficiency of health resource allocation in Sichuan Province and the five economic zones, we did not consider the actual demand for health services in each region, as well as the variability of individual demand and utilization of health services. Third, because the impact of population aging and changes in the disease spectrum are important factors to consider in health resource allocation, these aspects are not analyzed in this study.

Conclusions

From 2017 to 2021, health resources in Sichuan Province continue to grow, but equity has gotten worse. Compared with health technicians, licensed (assistant) physicians and registered nurses, the equity of the number of beds is better. The degree of variation in the allocation of health resources among the five major economic zones in Sichuan Province is large. The DEA is relatively ineffective in 2020 in Sichuan Province and the five major economic zones. The relative ineffectiveness of DEA exists in the PEZ, NESEZ and NWSEZ. The equity and efficiency of health resource allocation in Sichuan Province need to be improved. Only by continuously improving the equity and efficiency of health resource allocation in Sichuan Province can the multi-level and diversified medical needs of the people be better met. Therefore, Sichuan Province must optimize the allocation of health resources by taking into account factors such as population, geography, economy and the health status of the population, and strengthen the construction of health care systems in areas with weak health resources, in order to make the best possible use of health resources. This study still suffers from the limitations of selecting evaluation indicators that are commonly used in similar studies and not taking into account the actual health service needs of the regions. In the next step of the study, health resources can be predicted in terms of the actual demand for health services in each region, and the factors influencing the allocation of health resources in Sichuan Province can also be analyzed, in order to better optimize the allocation of health resources in Sichuan Province. We found that the equity and efficiency of health resource allocation in Sichuan Province needs to be improved, which is conducive to targeted measures to promote the development of health resources in Sichuan Province, enhance the balanced accessibility of health resource allocation in Sichuan Province, and promote health equity.

Authors’ contributions

ZMH conducted research design, data collection, writing and revision, and all authors read and approved the final manuscript.

Funding

This work was supported by Health Commission of Sichuan Province Medical Science and Technology Program (24WSXT019) and the primary health development research center of Sichuan Province program (SWFZ24-Y-36).

Data availability

The datasets supporting the study are publicly available on the Sichuan Health Statistics Yearbook (https://wsjkw.sc.gov.cn/scwsjkw/njgb/tygl.shtml) and Sichuan Statistical Yearbook (http://tjj.sc.gov.cn/scstjj/c105855/nj.shtml). The specific situation has been explained in the text.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.