Impact of health workforce availability on health care seeking behavior of patients with diabetes mellitus in China

BACKGROUND China has a high burden of diabetes mellitus (DM), and a large proportion of DM patients remain untreated for various reasons, including low availability of primary health care providers. DM patient management is one of the priorities in China's national essential public health programs. Shortage of health workforce has been a major barrier to improving access to health care for DM patients. This study examines the impact of the health workforce on outpatient utilization of DM patients. METHODS Data were collected from China National Health Service Surveys in 2008 and 2013, covering 94 rural counties and 156 urban districts, respectively, with a total of 15,984 DM patients. Household data and facility-based data at county/district level were merged. The health workforce was measured by number of physicians per 1,000 population in county hospitals and primary health centers (PHCs), respectively. Health care seeking behavior was measured by health care utilization and distribution of health providers of the DM patients. Multilevel zero-inflated negative binomial regression was used to analyze the impact of the health workforce on outpatient visits by DM patients, and a multilevel, multinomial logit model was used to examine the impact of the health workforce on choice of health providers by DM patients. RESULTS An increase in the number of physicians at both county hospitals and PHCs was associated with increased outpatient visits by DM patients, particularly more physicians at PHCs. With increased numbers of physicians at PHCs, outpatient visits among residents with DM in rural and western areas of China increased more than those in urban and eastern areas. More physicians at PHCs had a positive impact on improving the likelihood of outpatient visits at PHCs. The positive influence of increasing the number of physicians available to DM patients in rural and western areas was greater than that for urban and eastern DM patients. CONCLUSIONS The health workforce is a key component of any healthcare system and is critical in improving health care accessibility. Strategies to increase coverage of health workforce at PHCs are crucial to achieving adequate levels of health services for DM patients. Allocation of health workforce should focus on PHCs in rural and low-income areas.