中国分级诊疗体系对医疗资源配置的影响-动脉网

The impact of the hierarchical medical system on medical resource allocation in China

Nature 等信源发布 2025-03-04 19:47

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可切换为仅中文

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Abstract

摘要

The disparity in medical resource distribution across regions poses a significant challenge to healthcare reform in China. To address this, China has introduced the hierarchical medical system (HMS). This study evaluates the HMS’s impact on the equitable distribution of medical resources. We employ the Theil index to quantify the equalization of resources among cities within provinces and use a multi-period difference-in-differences model to assess the HMS’s influence.

区域间医疗资源分布的差异对中国医疗改革构成了重大挑战。为解决这一问题，中国引入了分级医疗制度（HMS）。本研究评估了HMS对医疗资源公平分布的影响。我们使用Theil指数量化各省内地级市之间资源的均等化程度，并采用多期双重差分模型评估HMS的影响。

Our findings indicate that the HMS has significantly contributed to the equal distribution of medical material resources, although its effect on medical human resources is less pronounced. Additionally, we explore the influencing factors of the HMS from the perspective of supply and demand and find that it is more effective in areas with abundant resources and high demand for high-level medical services.

我们的研究结果表明，HMS显著促进了医疗物资资源的均衡分布，但其对医疗人力资源的影响较不明显。此外，我们从供需角度探讨了HMS的影响因素，发现它在资源丰富且对高端医疗服务需求高的地区更为有效。

More importantly, the HMS has played an important role in mitigating medical disparities in regions with unbalanced economic statuses. These insights are instrumental for policymakers, guiding the evolution of healthcare reforms and the refinement of the HMS to achieve the objective of universal health coverage..

更重要的是，HMS在缓解经济状况不平衡地区的医疗差异方面发挥了重要作用。这些见解对政策制定者至关重要，指导着医疗改革的推进和HMS的完善，以实现全民健康覆盖的目标。

Introduction

简介

In the past four decades, China has experienced a substantial expansion in its medical resources. Specifically, from 1978 to 2023, the bed capacity in healthcare institutions per 1000 individuals has increased from 2.1 to 7.23, while the number of licensed (assistant) doctors per 1000 individuals has increased from 1.08 to 3.40.

在过去四十年中，中国的医疗资源经历了大幅扩张。具体而言，从1978年到2023年，每千人医疗卫生机构的床位数从2.1张增加到7.23张，而每千人执业（助理）医生数量从1.08人增加到3.40人。

These increases suggest that China is nearing the doctor-to-population ratios observed in many developed countries, and in terms of bed availability, it even surpasses some of these nations. Despite this progress, the allocation of medical resources in China has historically been restricted by public budgetary constraints.

这些增长表明，中国正在接近许多发达国家的医患比例，而在床位可用性方面，甚至超过了其中一些国家。尽管取得了这一进展，但中国医疗资源的分配历来受到公共预算限制的影响。

, leading to an emphasis on efficiency and a concentration of resources in economically developed regions, including provincial capitals, regional centers, and major cities. In the spatial distribution of medical resources, GDP strongly correlates with the supply of medical resources in China, whereas demographic factors show weak correlations.

，导致资源集中在经济发达地区、省会城市、区域中心和大城市，强调效率。在医疗资源空间分布上，国内生产总值与中国医疗资源供给呈强相关，而人口因素则表现出弱相关。

. This concentration results in substantial patient migration across regions

. 这种集中导致了跨地区的大量患者流动。

, which in turn puts immense pressure on medical resource hubs

，这反过来又给医疗资源中心带来了巨大的压力

and increases the expense of medical services

并增加了医疗服务的费用

. The uneven distribution of medical resources has also contributed to disparities in medical utilization

医疗资源分布不均也导致了医疗服务利用方面的差异

and health outcomes

和健康结果

，

. “It is difficult and expensive to see a doctor” (commonly known as

“看病难且昂贵”（俗称

kan-bing-nan

看病难

，

kan-bing-gui

看病贵

in Chinese) has become a significant problem that runs counter to the goal of universal health coverage

已成为违背全民健康覆盖目标的重大问题

. Prioritizing the geographic balance and coordination of medical resources is essential for reforming China’s medical system

优先考虑医疗资源的地理平衡和协调是中国医疗体制改革的关键。

。

Faced with the increasingly severe issue of

面对日益严峻的问题

kan-bing-nan

看病难

and

和

kan-bing-gui

看病贵

, China took a significant step in March 2009 by issuing the “Opinions of the CPC Central Committee and the State Council on Deepening the Health Care System Reform,” commonly referred to as the new healthcare reform

，中国在2009年3月通过发布《中共中央国务院关于深化医药卫生体制改革的意见》迈出了重要的一步，这通常被称为新医改。

. This reform aims to strengthen the government’s financial commitment to healthcare and is a crucial component of the China’s efforts to address the challenges in the medical sector

这项改革旨在加强政府对医疗保健的财政承诺，是中国应对医疗领域挑战努力的关键组成部分。

，

. A key aspect of the new healthcare reform is the establishment of the hierarchical medical system (HMS). One of the primary goals of the HMS is to ensure that residents can receive treatment for serious illnesses within their province, minor ailments within their county, and routine conditions at the township level.

新医改的关键环节是建立分级诊疗制度，其主要目标是确保居民大病不出省、小病不出县、常见病在乡镇。

Therefore, on the supply side of medical resources, the HMS focuses on promoting the decentralization of medical resources to ensure a balanced regional layout and also strictly regulates the uncontrolled growth of large healthcare facilities.

因此，在医疗资源的供给侧，HMS专注于推动医疗资源的分散化，以确保区域布局的平衡，并严格监管大型医疗机构的无序扩张。

. The central government encouraged all localities to carry out practice innovation of the HMS since 2009. However, no specific HMS policies were implemented initially. Until 2012, several provinces explored the HMS as pilots. Although the HMS has been in place for a long time, its effects are still not well understood..

自2009年以来，中央政府鼓励各地开展HMS的实践创新。然而，最初并没有实施具体的HMS政策。直到2012年，一些省份开始进行HMS试点探索。尽管HMS已经实施了很长时间，但其效果仍然没有得到充分理解。

Research on the implementation effect of the HMS in China is limited, primarily focusing on patients’ health-seeking behavior and medical resource utilization. Zhou et al.

对中国HMS实施效果的研究有限，主要集中在患者的就医行为和医疗资源利用方面。周等人。

find that while the HMS has successfully steered urban residents towards primary care facilities for initial consultations, its impact in rural regions has been less pronounced. The HMS combined with the online appointment diagnosis system has shown promise in improving patient distribution across various healthcare facilities.

发现虽然HMS成功引导城市居民前往基层医疗机构进行初步问诊，但其在农村地区的影响较小。HMS结合在线预约诊断系统在改善患者在不同医疗机构间的分布展现了潜力。

. However, the effectiveness of such technological integration may depend on factors like internet accessibility and digital literacy. Some studies have examined the impact of the HMS in a single pilot area. Evidence from Yinzhou district, Ningbo, the HMS redirected patient flows to primary care facilities and promoted the centrality of primary care doctors within their professional network, suggesting improved coordination and integration of care for patients with hypertension.

然而，这种技术整合的有效性可能取决于互联网可访问性和数字素养等因素。一些研究考察了HMS在单个试点地区的影响。来自宁波鄞州区的证据表明，HMS将患者流量重新导向至初级医疗机构，并提升了初级保健医生在其专业网络中的核心地位，表明高血压患者的护理协调性和整合性得到了改善。

. A study in Shanghai showed the short-term benefits of the HMS on medical performance in central districts and indicated spatial variation in its impact

上海的一项研究表明，HMS对中心城区的医疗绩效有短期效益，并指出其影响存在空间差异。

. Wu et al.

吴等。

evaluated the operational efficiency of the HMS in primary medical and health institutions in Fujian Province and found the redundancy rate was generally high. Few studies pay attention to the effect of the HMS on the supply side. Although Lu et al.

评估了福建省基层医疗卫生机构HMS的运行效率，发现冗余率普遍较高。少数研究关注HMS对供给侧的影响。尽管Lu等人。

take Beijing as an example to analyze the impact of the HMS on the fairness and spatial accessibility of medical resources, their study is limited to observations within a single pilot city, which lacks extensive investigation into the broader implications of the HMS.

以北京为例分析HMS对医疗资源公平性和空间可及性的影响，但其研究局限于单个试点城市的观察，缺乏对HMS更广泛影响的深入调查。

This paper evaluates the pilot of the HMS implemented at the provincial level, intending to provide policy implications for further implementation in China. First, the Theil index measures the equalization level between cities in each province. Second, to observe whether the policy has promoted equalization, the difference-in-differences(DID) model is used to evaluate the changes after implementing the HMS.

本文评估了在省级层面实施的HMS试点，旨在为中国进一步实施提供政策启示。首先，使用Theil指数衡量各省份内城市间的均等化水平。其次，为观察该政策是否促进了均等化，采用双重差分（DID）模型评估HMS实施后的变化。

The results indicate that the HMS has had a significant positive effect on equalizing the medical material resources supply between cities in the province. However, the equalization effect of medical human resources in the province is insignificant. After conducting the parallel trend test and placebo tests, and replacing different equalization measurement methods, the above main findings remain robust.

结果表明，HMS 对于促进省内城市间医疗物质资源供给的均等化有显著正向作用，但对省内医疗人力资源的均等化效果不明显。经过平行趋势检验、安慰剂检验以及更换不同的均等化测度方法后，上述主要发现依然稳健。

Third, we discuss the impact of the HMS on resource allocation from the perspective of supply and demand and find that the effect of the HMS on promoting equalization is stronger in areas with the high supply of medical resources and high demand for high-level medical resources. At the same time, we investigate the impact of the HMS on medical resource allocation under economic inequality and find that the HMS promoted the equalization of medical resource allocation in areas with unequal economic development..

第三，从供需角度探讨了HMS对资源配置的影响，发现HMS在医疗资源供给充足、对高水平医疗资源需求旺盛的地区，其促进均等化的效果更强。同时，考察了经济不平等情况下HMS对医疗资源配置的影响，发现HMS促进了经济发展不平等地区的医疗资源分配均等化。

There are three marginal contributions in this paper. First, our knowledge indicates that even though a few studies explored the effect of the HMS on the medical demand side, the impact of the HMS on the medical supply side has not yet been investigated. Second, we first use a rigorous empirical strategy to investigate the impact of the HMS on equalizing medical resources, which is instructive for thinking about how to improve the HMS from the supply side further to promote fairness.

本文有三个边际贡献。首先，我们的研究指出，尽管已有少数研究探讨了HMS对医疗需求方的影响，但其对医疗供给方的影响尚未得到探究。其次，我们首次采用严谨的实证策略，分析HMS对均衡医疗资源的影响，这对思考如何从供给侧进一步完善HMS以促进公平性具有指导意义。

Third, we discuss the role of high supply and high-level hospital demand in promoting the equalization of medical resources and the possibility of the HMS breaking the economic constraints of medical resource equalization. What role the government should play in realizing the equalization of medical services is an essential issue in health economics and public management.

第三，探讨高度的供给和高水平的医院需求在促进医疗资源均等化中的作用，以及卫生部系统打破医疗资源均等化的经济约束的可能性。政府在实现医疗服务均等化中应扮演什么角色是卫生经济学和公共管理中的重要问题。

The policy practice in China and this study may also benefit the field’s growth..

中国的政策实践和本研究也可能有利于该领域的发展。

Conceptual framework

概念框架

In 1978, China embarked on market-oriented reforms, transitioning its economy from a centrally planned system to one driven by market dynamics

1978年，中国开始了以市场为导向的改革，将其经济从中央计划体系转变为由市场力量驱动的体系。

. These reforms dismantled egalitarian policies that had previously ensured the equal distribution of resources across the nation

这些改革瓦解了之前确保全国资源平等分配的平等主义政策。

. Although the primary objective of the reforms was to stimulate economic growth and development, they inadvertently altered the distribution of resources within the healthcare sector. The marketization of the economy spurred rapid growth and expansion in the medical sector, which was initially perceived as a positive outcome.

虽然改革的主要目的是刺激经济增长和发展，但它们却意外地改变了医疗行业内的资源分配。经济的市场化促进了医疗行业的快速成长和扩张，最初这被视为一个积极的结果。

However, this expansion was not uniformly distributed. It led to a concentration of medical resources in economically prosperous regions, resulting in a relative scarcity of medical facilities and professionals in less developed areas.

然而，这种扩张并非均匀分布。它导致了医疗资源集中在经济繁荣的地区，从而使得欠发达地区的医疗设施和专业人员相对稀缺。

。

The implementation of the HMS has solidified the government’s primary responsibility in medical resource allocation and promoting equitable access to medical services

卫生部的实施巩固了政府在医疗资源配置和促进医疗服务公平可及方面的主体责任。

，

. The central government has delegated decision-making and management authority to provincial levels, guiding policy execution while allowing regional customization. This decentralization, coupled with provincial autonomy, ensures that HMS policies are tailored to local conditions, thereby enhancing the efficiency and relevance of healthcare delivery.

中央政府已将决策和管理权限下放给省级政府，在指导政策执行的同时允许区域定制。这种权力下放加上省级自治，确保了卫生系统政策因地制宜，从而提高了医疗服务的效率和相关性。

By setting clear standards and expectations, the central government ensures that the pilot programs are implemented effectively and that the benefits of the HMS are realized across the country..

通过设定明确的标准和期望，中央政府确保试点项目得到有效实施，并使HMS的优势在全国范围内实现。

Firstly, the HMS reinforces the responsibility of governments at all levels, on the guiding and constraining role in resource allocation. Local governments are tasked with developing and implementing healthcare service plans based on provincial guidelines and resource standards, ensuring a rational layout and efficient operation of the healthcare system.

首先，HMS强化了各级政府在资源配置中的指导和约束作用的责任。地方政府根据省级指导方针和资源标准制定并实施医疗卫生服务计划，确保医疗系统的合理布局和高效运行。

This includes the establishment of medical institutions through government funding or service procurement, and the rational division of service areas, with a focus on strengthening the basic medical service capabilities of township health centers. Additionally, the program encourages private medical practice by simplifying the approval process for individual clinics, enabling doctors to provide services in their communities..

这包括通过政府投入或购买服务等方式设立医疗机构，合理划分服务区域，重点加强乡镇卫生院的基本医疗服务能力。此外，该计划还通过简化个体诊所的审批流程来鼓励私人行医，使医生能够在社区内提供服务。

Secondly, the HMS addresses the gap in resources in less developed areas by adhering to the principle of “filling the gaps.” It focuses on enhancing the clinical specialty capabilities of county-level public hospitals, particularly in treating common and prevalent diseases, and appropriately relaxes restrictions on medical technology applications to improve the overall service capacity of these hospitals.

其次，HMS通过坚持“填坑”原则来解决欠发达地区资源缺口问题，重点提升县级公立医院临床专科能力，尤其是对常见病、多发病的诊治能力，并适度放宽医疗技术应用限制，提高这些医院的整体服务能力。

The HMS also streamlines the mobility and training of medical personnel by strategically rotating urban doctors to grassroots institutions and vice versa, fostering an environment for continuous learning and skill development. This approach facilitates the transfer of high-quality medical professionals from larger hospitals to other regions, ensuring a more balanced distribution of expertise.

HMS还通过将城市医生战略性地轮派到基层医疗机构，反之亦然，从而简化了医务人员的流动和培训，营造了一个持续学习和技能发展的环境。这种方法促进了高质量医疗专业人员从大型医院向其他地区转移，确保了专业知识的更均衡分布。

The national evaluation criteria for the pilot program require that counties with populations of over 300,000 have at least one secondary-level general hospital and one secondary-level traditional Chinese medicine hospital, with an in-county treatment rate of around 90%, essentially ensuring that major illnesses can be treated within the county..

全国试点评估标准要求，30万人口以上的县至少有一所二级甲等综合医院和一所二级甲等中医类医院，县域内就诊率达到90%左右，基本实现大病不出县。

Thirdly, the HMS controls the irrational expansion of individual public medical institution scales. It focuses on limiting the number and size of tertiary hospitals and establishing a bed control mechanism centered on disease structure, service coverage, task completion, talent training, and work efficiency.

第三，医联体控制单体公立医院的规模非理性扩张，重点是限制三级医院的数量和规模，建立以疾病结构、服务范围、任务完成、人才培养、工作效率为核心的床位调控机制。

This strict control over hospital bed expansion ensures that the growth of public hospitals is aligned with the needs and capabilities of the healthcare system, preventing overexpansion and maintaining a balanced distribution of medical resources..

对医院床位扩张的严格控制确保了公立医院的增长与医疗系统的需求和能力相一致，防止过度扩张，并维持医疗资源的均衡分布。

Hypothesis 1

假设1

The implementation of the HMS has led to more balanced medical resource allocation among cities in the province.

HMS的实施使得该省各城市之间的医疗资源分配更加均衡。

An important factor affecting the equalization of medical resources for the HMS is the total supply of medical resources. In provinces with abundant medical resources, there are typically more medical institutions, healthcare professionals (such as doctors and nurses), as well as better-equipped facilities, and advanced technologies.

影响 HMS 医疗资源均等化的一个重要因素是医疗资源的总供给。在医疗资源丰富的省份，通常会有更多的医疗机构、医疗专业人员（如医生和护士）、设施条件更好且技术更先进。

In such cases, implementing the HMS can effectively utilize these resources, improve the efficiency and quality of healthcare services, and better meet the needs of patients. Next, provinces with abundant medical resources often have well-established multi-level healthcare service networks that cover various levels of medical institutions, ranging from primary to advanced care.

在这种情况下，实施卫生管理系统可以有效利用这些资源，提高医疗服务的效率和质量，更好地满足患者的需求。接下来，医疗资源丰富的省份通常拥有完善的多层次医疗服务网络，覆盖从初级到高级护理的各级医疗机构。

These networks provide a solid foundation for the implementation of the HMS, enabling smooth patient referrals and appropriate medical services.

这些网络为实施卫生管理系统提供了坚实的基础，使患者转诊和适当的医疗服务得以顺利进行。

. Moreover, provinces with abundant medical resources usually have strong economic capabilities, which can better support the implementation of the HMS. Investing in the enhancement of service capabilities, and introduction of advanced technologies and equipment at primary healthcare institutions is required for the HMS.

此外，医疗资源丰富的省份通常经济实力较强，能够更好地支持卫生系统的实施。卫生系统需要投资于增强服务能力，以及在初级卫生保健机构引入先进技术和设备。

Provinces with abundant medical resources are more likely to bear these costs and provide robust support for the promotion and operation of the HMS..

医疗资源丰富的省份更有可能承担这些费用，并为HMS的推广和运营提供有力支持。

Hypothesis 2

假设2

Provinces with abundant medical resources are more capable of promoting medical resource equalization after the HMS.

医疗资源丰富的省份在实行医保制度后更有能力促进医疗资源的均等化。

Another important factor affecting the equalization of medical resources for the HMS is the intensity of patient demand. Patients tend to concentrate their visits to higher-level medical institutions when there is a high demand for quality medical resources. This means that these advanced medical institutions may become overloaded with medical tasks, while resources at the primary institutions may be underutilized, resulting in an excessive concentration of resources and an imbalance in resource utilization.

另一个影响 HMS 医疗资源均等化的重要因素是患者需求的强度。当对优质医疗资源的需求较高时，患者往往倾向于将就诊集中在更高级别的医疗机构。这意味着这些高级医疗机构可能面临医疗任务过载的情况，而基层医疗机构的资源则可能未被充分利用，从而导致资源过度集中和资源利用的不平衡。

. In provinces facing more intensity of medical tasks in high-level medical institutions, the HMS allows for a more balanced allocation of resources across different levels of medical institutions through classification and patient referral, which helps alleviate the burden on higher-level medical institutions.

在高层次医疗机构面临较重医疗任务的省份，HMS通过分类和转诊使不同层次的医疗机构资源分配更加均衡，有助于减轻高层级医疗机构的负担。

Therefore, provinces with a high demand for quality medical resources are more motivated to optimize the distribution of medical resources may lead to better promotion of equalization..

因此，对优质医疗资源需求较高的省份更有动力优化医疗资源的配置，这可能会更好地促进均等化。

Hypothesis 3

假设3

Provinces with a high demand for quality medical resources are more motivated to promote medical resource equalization after the HMS.

对优质医疗资源需求较高的省份在HMS后更有动力推动医疗资源均等化。

Economic development is the material basis for providing basic medical services

经济发展是提供基本医疗服务的物质基础。

，

. In China, due to the imbalanced economic development, the difference in financial income capacity at all levels, and the difference in medical input cost, the imbalanced supply of primary medical services in China has been prominent for a long time. In other words, the more imbalanced the regional economic development is, the more unequal the allocation of medical resources will be.

在中国，由于经济发展不平衡，各级财政收入能力差异以及医疗投入成本差异，导致我国基本医疗服务供给长期存在不平衡的状况。也就是说，区域经济发展越不平衡，医疗卫生资源分配越不均衡。

By strengthening the construction of primary medical institutions and improving their service capacity, the HMS enables residents in economically underdeveloped areas to obtain basic medical services nearby. Hence, we propose the following hypothesis:.

通过加强基层医疗机构建设、提升其服务能力，HMS使经济欠发达地区的居民能够就近获得基本医疗服务。据此，提出以下假设：。

Hypothesis 4

假设 4

The HMS can mitigate the inequality of medical resource supply caused by economic imbalance.

HMS可以缓解由经济失衡导致的医疗资源供给不均问题。

In summary, the HMS enhances government accountability, addresses resource deficiencies in underdeveloped regions, and regulates the growth of public hospitals, all with the goal of fostering a more equitable medical resource allocation. Moreover, the equalization effect of the HMS may be influenced by supply abundance, demand intensity, and economic imbalance.

总之，HMS增强了政府的责任感，解决了欠发达地区的资源不足问题，并规范了公立医院的增长，所有这些都旨在促进更公平的医疗资源分配。此外，HMS的均等化效应可能会受到供应充足性、需求强度和经济不平衡的影响。

We developed our conceptual framework and summarized it in Fig. .

我们开发了我们的概念框架并将其总结在图中。

。

Fig. 1

图1

Conceptual framework.

概念框架。

Full size image

全尺寸图像

Methodology and data

方法论与数据

Explained variable

被解释变量

The number of beds is employed as a proxy for medical material resources. The quantity of beds is one of the key indicators for assessing the scale and capacity of medical institutions

床位数量被用作医疗物资资源的替代指标。床位数量是评估医疗机构规模和容量的关键指标之一。

. A higher number of beds signifies that a medical institution can accommodate a larger number of patients simultaneously, thereby offering a greater volume of medical services. The number of beds in this study differs from inpatient beds, encompassing a broader range and adhering to a fixed statistical methodology in China.

床位数量越多，意味着医疗机构能够同时容纳更多的患者，从而提供更大体量的医疗服务。本文中的床位数与住院床位数不同，它涵盖范围更广，并遵循中国固定的统计口径。

According to the bed count statistical criteria published by the National Bureau of Statistics of China.

根据中国国家统计局发布的床位数统计标准。

, the scope of bed count statistics for medical institutions includes public hospitals and private hospitals; health clinics; maternal and child health institutions; specialized disease prevention and treatment institutions; and community health service institutions. This refers to the fixed and actual number of beds in medical institutions, including regular beds, simple beds, intensive care beds, additional beds for more than half a year, beds undergoing disinfection and repair, and beds damaged due to recent or major renovations.

，医疗卫生机构床位统计范围包括公立医院、民营医院、卫生院、妇幼保健机构、专科疾病防治机构、社区卫生服务机构等，指医疗单位固定实有床位数，包括正规床、简易床、监护床、半年以上加床、消毒和修理床、因近期或大型装修损坏的床等。

It does not include beds for newborns in obstetrics, beds for labor in delivery rooms, beds in storage, observation beds, temporary additional beds, and some beds for patient companions..

它不包括产科的新生儿床位、分娩室的待产床位、库存床位、观察床位、临时增加的床位以及部分患者陪护床位。

Additionally, the number of licensed (assistant) doctors is employed as a proxy for medical human resources. Licensed (assistant) doctors refer to medical workers who have obtained the licenses of qualified (assistant) doctors and are employed in medical treatment, disease prevention, or healthcare institutions, excluding those licensed doctors engaged in management positions.

此外，执业（助理）医师数量作为医疗人力资源的代理变量。执业（助理）医师是指取得执业（助理）医师资格证，并在医疗机构、预防保健机构中从事医疗工作的人员，不包括从事管理岗位的执业医师。

Licensed doctors are categorized into four groups: clinicians, Chinese medicine physicians, dentists, and public health physicians.

执业医师分为四类：临床医师、中医医师、牙医和公共卫生医师。

. The registration of doctors refers to the assessment of whether doctors have industry qualifications, which are uniformly issued by the National Health Commission with a nationally standardized entry threshold and must be registered in a standardized manner within medical institutions. Only after obtaining the licenses of qualified doctors and being granted the corresponding prescription rights in the registered medical institution can they prescribe for patients in clinical activities.

医生注册是指对医生是否具备行业资格的评估，这些资格由国家卫生健康委员会统一颁发，具有全国统一的准入门槛，并且必须在医疗机构内进行规范注册。只有取得合格医生执照并在注册医疗机构被授予相应处方权后，才能在临床活动中为患者开处方。

Previous studies using the same dimension as ours also represent the richness of medical human resources with the licensed (assistant) doctors.

以往使用与我们相同维度的研究也用执业（助理）医生来表征医疗人力资源的丰富程度。

，

。

There are many methods to measure the degree of equalization, mainly including the Theil index method, coefficient of variation method, Gini coefficient method, and concentration index

衡量均衡程度的方法有很多，主要包括Theil指数法、变异系数法、基尼系数法以及集中指数法。

. The Theil index, based on entropy from information theory, is a classic tool for measuring income inequality and has been used to assess disparities across regions. The decomposable nature of the Theil index and its sensitivity to the changes of upper and lower layers, and then widely used to study overall regional differences and regional differences in medical resources.

基于信息论中的熵理论的泰尔指数是衡量收入不平等的经典工具，已被用于评估区域间的差异。泰尔指数的可分解性及其对上下层变化的敏感性，使其被广泛用于研究整体区域差异和医疗资源的区域差异。

，

. In the traditional sense, the Theil index is weighted by GDP or resource quantity, called the Theil-T index; another form of generalized entropy index, weighted by the proportion of the population, is called the Theil-L index. The Theil-T index is sensitive to the change in upper income, while the Theil-L index is sensitive to the change in lower income.

传统意义上的泰尔指数是按GDP或资源数量加权的，称为Theil-T指数；另一种广义熵指数形式，按人口比例加权的，称为Theil-L指数。Theil-T指数对高收入部分的变化较为敏感，而Theil-L指数则对低收入部分的变化较为敏感。

In the baseline regression model, the Theil-T index is considered the main measurement index of the equalization of medical resource supply in each province. The Theil-L index and coefficient of variation are used as the robustness test..

在基准回归模型中，Theil-T指数被视为各省医疗资源供给均等化的主要衡量指标，Theil-L指数和变异系数则作为稳健性检验。

From the perspective of medical resource allocation, existing studies generally examine the equalization of the medical resource supply side from three aspects: human, material, and financial resources. The direct output of the government’s financial investment in medical and health undertakings is the increase of medical human and material resources.

从医疗卫生资源配置的角度来看，现有研究一般从人、财、物三方面考察医疗卫生资源供给方的均等化状况，政府财政对医疗卫生事业的投入直接产出的是医疗卫生人、物力资源的增加。

Considering data availability, this study only analyzes the equalization level of medical human resources and material resources in China. The formula for calculating the Theil-T index between cities in the province is set as follows:.

考虑到数据的可得性，本研究仅分析中国医疗卫生人力资源和物力资源的均等化水平。省内城市间泰尔T指数的计算公式设置如下：

$$Theil_{i}^{T} = \mathop \sum \limits_{j}^{N} \left( {\frac{{Y_{{ij}} }}{{Y_{i} }}} \right)\log \left( {{{\frac{{Y_{{ij}} }}{{Y_{i} }}} \mathord{\left/ {\vphantom {{\frac{{Y_{{ij}} }}{{Y_{i} }}} {\frac{{P_{{ij}} }}{{P_{i} }}}}} \right. \kern-\nulldelimiterspace} {\frac{{P_{{ij}} }}{{P_{i} }}}}} \right)$$.

$$Theil_{i}^{T} = \sum_{j}^{N} \left( \frac{Y_{ij}}{Y_{i}} \right) \log \left( \frac{\frac{Y_{ij}}{Y_{i}}}{\frac{P_{ij}}{P_{i}}} \right)$$。

(1)

where

其中

$Y_{ij}$

denotes the medical resource supply of the city

表示城市的医疗资源供应

$j$

in the province

在省内

$i$

, and

，以及

$Y_{i}$

denotes the medical resource supply of the province

表示该省的医疗资源供应

$i$

。

$P_{ij}$

is the population of the city

城市的人口是

$j$

in the province

在省内

$i$

, and

，以及

$P_{i}$

is the population of the province

是该省的人口数量

$i$

。

The range of the Theil index is from 0 to 1. When the Theil index equals 0, this region’s medical resource allocation is absolute fairness. The closer the Theil index is to 1, the more imbalanced medical resource allocation is in this region.

Theil指数的范围是从0到1。当Theil指数等于0时，该地区的医疗资源分配是绝对公平的。Theil指数越接近1，该地区的医疗资源分配就越不平衡。

Core explanatory variable

核心解释变量

We searched the official website of the provincial government and the official website of the Department of Health and Health Commission, with “Hierarchical Medical System” as the core keyword, supplemented by the same keyword in the Peking University Law’s Local Laws and Regulations Database. When the policy document first proposes “the establishment of the HMS” in the province, we consider that time point to be the beginning of the establishment of the HMS in that province.

我们检索了省政府官网、省卫健委官网，以“分级诊疗”为核心关键词，并辅以北大法宝地方法律法规数据库中相同关键词进行检索。当某政策文件首次提出在该省“建立分级诊疗制度”时，我们认为这个时间点是该省分级诊疗制度建立的起点。

Furthermore, if documents are released in the first half of the year, they are presumed to be implemented within the same year. Conversely, documents released in the second half of the year are assumed to be implemented in the subsequent year. Additionally, the documents issued by pilot provinces regard the construction of the HMS as a lasting task, and there is no situation in which provinces withdraw after the pilot..

此外，上半年出台的文件，一般推定为当年落实；下半年出台的文件，则视作次年落实。另外，各试点省份对于建设卫生医疗系统（HMS）视为一项长期任务，不存在试点结束后省份退出的情形。

Empirical strategy

实证策略

To evaluate the impact of the HMS on equalization, we apply the DID strategy with two-way fixed effects (TWFE). As the HMS is implemented by region and year by year, referring to the research design of Beck et al.

为了评估HMS对均衡化的影响，我们采用双向固定效应（TWFE）的DID策略。由于HMS是按地区逐年实施的，参考了Beck等人的研究设计。

, the DID model with multiple periods is adopted to estimate the implementation effect of the HMS, and the following econometric regression model is specifically set:

，采用多期DID模型来评估HMS的实施效果，并具体设定以下计量回归模型：

$$Y_{it} = \beta_{0} + \beta^{did} HMS_{it} + \lambda Control_{it} + v_{i} + \mu_{t} + \varepsilon_{it}$$

(2)

where

其中

$Y_{it}$

denotes the equalization of the medical resource supply of the province

表示该省医疗资源供应的均衡化

$i$

in year

在某年

$t$

. The key independent variable,

。关键的自变量，

$HMS_{i}$

, is a dummy variable for the province

，是省份的虚拟变量

$i$

treatment status. If the province

治疗状态。如果省份

$i$

implements HMS in year

在年内实施HMS

$t$

, then

，然后

$HMS_{i}$

takes the value 1 for the city in year

在这一年中，城市取值为1

$t$

and later, and 0 for the year before.

之后，以及之前一年的0。

$Control_{it}$

is a set of control variables.

是一组控制变量。

$v_{i}$

is province fixed effects,

是省份固定效应，

$\mu_{t}$

is year fixed effects and

今年是固定效应和

$\varepsilon_{it}$

is random error term.

是随机误差项。

The important premise of the DID is to satisfy the parallel trend assumption, that is, there is no significant difference between the experimental group and the control group before the HMS. To test the parallel trend of DID with multiple periods, refer to the event study method and then set up the following model:.

DID的重要前提是满足平行趋势假设，即在HMS之前，实验组和对照组之间没有显著差异。为了检验多期DID的平行趋势，参考事件研究法，然后设定以下模型：。

$$Y_{it} = \alpha_{0} + \sum\limits_{k \ge - 5,k \ne - 1}^{5} {\alpha_{k} D_{it}^{k} } + \lambda Control_{it} + v_{i} + \mu_{t} + \varepsilon_{it}$$

(3)

In the formula (

公式（

$D^{k}_{it}$

is a set of dummy variables representing an event dummy variable for a specific period. Assumed that the implementation time point of the HMS owned by the province is

是一组代表特定时期事件虚拟变量的虚拟变量。假设该省拥有的HMS的实施时间点是

$year_{i}$

$年份_{i}$

, let

，让

$k = t - year_{it}$

, when

，当

$k \le - 5$

，

$D^{ - 5}_{it} = 1$

, otherwise it is 0; when

，否则为0；当

$k = - 5, - 4,\ldots , - 2,0,1,\ldots ,4,5$

$k = -5, -4, \ldots, -2, 0, 1, \ldots, 4, 5$

, and

，以及

$D^{k}_{it} = 1$

, otherwise it is 0; when

，否则为0；当

$k \ge - 5$

，

$D^{k}_{it} = 1$

, otherwise it is 0. In this study,

，否则为0。在这项研究中，

$k = - 1$

is used as the base period. For the specific calculation, the term

被用作基期。对于具体的计算，术语

$D^{ - 1}_{it}$

in formula (

在公式（

) will be removed. By comparing the significance of the estimated coefficients

）将被移除。通过比较估计系数的重要性

$\alpha_{k}$

when

当

$k \le - 2$

, we can judge whether it satisfies the parallel trend assumption. If the coefficients,

，我们可以判断它是否满足平行趋势假设。如果系数，

$\alpha_{k}$

, are not significant, it means that there is no significant difference between the experimental group and the control group in the trend of the equalization of medical resource supply before the HMS, and the parallel trend assumption holds. In addition, when

，不显著，则说明在HMS之前，实验组与对照组在医疗资源配置均等化趋势上没有显著差异，平行趋势假设成立。此外，当

$k \ge 0$

, we can also test the dynamic effect of the HMS by observing the significance of the coefficients

，我们还可以通过观察系数的显著性来测试HMS的动态效应。

$\alpha_{k}$

, that is, observe whether the effect of the HMS changes in the year when the HMS is implemented and in the following years. We incorporate a series of time-varying covariates,

，即观察HMS实施当年及随后几年HMS的效果是否发生变化。我们纳入了一系列随时间变化的协变量，

$Control_{it}$

, at the provincial level as control variables, aiming to isolate the net effect of policy implementation. First, considering the significant differences in economic development levels among provinces, which may directly affect the allocation of medical resources

，以省级层面的因素作为控制变量，旨在分离出政策实施的净效应。首先，考虑到各省经济发展水平存在显著差异，这可能直接影响医疗资源的分配。

, we introduced the Theil index calculated based on GDP disparities to reflect the imbalance of economic development. Second, to account for the impact of unbalanced consumption capacity, we employed the Theil index of the total retail sales of consumer goods as an indicator, as consumption levels in different areas reflect the quality of life and medical service demands of local residents.

我们引入了基于GDP差异计算的泰尔指数来反映经济发展的不平衡性；其次，为了考虑消费能力不均衡的影响，我们采用了社会消费品零售总额的泰尔指数作为指标，因为不同地区的消费水平反映了当地居民的生活质量和医疗服务需求。

. Third, with the development of information technology and its changes to the way health information is accessed

第三，随着信息技术的发展及其对健康信息获取方式的改变

，

, we also took into account the gap in information acquisition between cities, quantifying it through the Theil index of information disparities based on the number of Internet users. Additionally, the Theil index is between 0 and 1, we employed the panel Tobit model as a robustness check.

，我们还考虑了城市间信息获取的差距，并通过基于互联网用户数量的信息差异Theil指数对其进行量化。此外，由于Theil指数介于0和1之间，我们采用了面板Tobit模型作为稳健性检验。

Data description

数据描述

The data were drawn from the China City Statistical Yearbook from 2010 to 2019. When calculating the Theil index between cities in each province, we made use of the number of beds and the number of licensed (assistant) doctors in medical and health institutions at the city (whole city) level in the China City Statistical Yearbook of each city over the years, and the missing values of some years’ data at the city level were filled up by linear interpolation, and finally, the inter-city equalization level of 23 provinces was obtained.

数据来源于2010-2019年《中国城市统计年鉴》。在计算各省份内城市间的泰尔指数时，我们利用了各城市历年《中国城市统计年鉴》中医疗卫生机构的床位数和执业（助理）医师数在市（全辖区）层面的数据，并通过线性插值法填补了部分年份市级数据的缺失值，最终得到23个省份的城市间均等化水平。

Table .

表格。

shows the descriptive statistical results.

显示了描述性统计结果。

Table 1 Summary statistics.

表1 摘要统计。

Full size table

全尺寸表格

Results

结果

The results of the Theil index

Theil指数的结果

Table

表格

presents Theil indices for the distribution of medical resources, across various provinces in China for the years 2010 and 2019. The Theil index measures inequality, with lower values indicating more equitable distribution. The overall trend shows that most provinces experienced a decrease in the Theil index for beds from 2010 to 2019, indicating a more balanced distribution of medical material resources over this period.

展示了2010年和2019年中国各省份医疗资源分布的泰尔指数。泰尔指数衡量不平等程度，数值越低表示分布越均衡。总体趋势显示，大多数省份在2010年至2019年间床位的泰尔指数下降，表明这一时期医疗物质资源的分布更加平衡。

Similarly, the Theil index for the number of licensed (assistant) doctors generally decreased across most provinces, reflecting improved equity in medical human resources distribution from 2010 to 2019..

同样，2010年至2019年，大多数省份的注册（助理）医生数量的泰尔指数普遍下降，反映了医疗人力资源分配的公平性有所改善。

Table 2 Theil index.

表2 泰尔指数。

Full size table

全尺寸表格

Table

表格

reveals considerable disparities in the equity of medical resource distribution among different provinces. For example, in 2019, Guangdong Province had a Theil index of 0.1709 for beds, whereas Zhejiang Province had a much lower index of 0.0410, indicating more equitable distribution in Zhejiang. Most provinces have shown improvements in the equitable distribution of medical resources between 2010 and 2019, suggesting a nationwide trend toward more balanced medical resource allocation..

揭示了不同省份之间医疗资源分配的公平性存在显著差异。例如，2019年广东省床位的泰尔指数为0.1709，而浙江省的指数则低得多，为0.0410，表明浙江的分配更加公平。大多数省份在2010年至2019年间医疗资源分配的公平性有所改善，显示出全国范围内医疗资源分配趋于平衡的趋势。

Conversely, provinces like Henan (beds, from 0.0477 to 0.0813) experienced growing disparities in medical material resources. Yunnan (doctors, from 0.1557 to 0.4032) and Gansu (doctors, from 0.0692 to 0.1239) witnessed substantial increased disparities in medical human resources. These findings on the equalization level of medical resources within provinces calculated by the Theil index are comparable to previous studies.

相反，像河南（床位，从0.0477到0.0813）这样的省份在医疗物质资源方面的差距正在扩大。云南（医生，从0.1557到0.4032）和甘肃（医生，从0.0692到0.1239）在医疗人力资源方面的差距显著增大。这些通过泰尔指数计算的省内医疗资源均等化水平的研究结果与以往的研究具有可比性。

，

。

Benchmark analysis

基准分析

Table

表格

reports the estimation results of Eq. (

报告了方程的估计结果。

), in which models (1) and (3) control the year and province fixed-effect, and models (2) and (4) report the estimation results after adding control variables. The estimation results of models (1) and (2) show that the estimation coefficients of dependent variables to Bed_bc are negative at the 5% significance level and negative at the 1% significance level after adding control variables.

），其中模型（1）和（3）控制了年份和省份固定效应，模型（2）和（4）报告了加入控制变量后的估计结果。模型（1）和（2）的估计结果显示，因变量对Bed_bc的估计系数在5%显著性水平上为负，在加入控制变量后于1%显著性水平上仍为负。

The value of the Theil index ranges from 0 to 1, and the closer it is to 0, the higher the level of equalization between cities in the province is. The estimated result of model (2) shows that the Theil index has dropped by 0.009 on average, which indicates that the implementation of the HMS has promoted the equalization of medical material resources between cities in the province.

Theil指数的取值范围为0到1，越接近于0表示省内城市间的均等化程度越高。对模型（2）的估计结果显示，Theil指数平均下降了0.009，这表明HMS的实施促进了省内城市间医疗物质资源的均等化。

Based on the average value of the Theil index of 2012, the decreases are about 18.5%. The estimated results of models (3) and (4) are negative but not significant, which indicates that the implementation of the HMS may not significantly promote the equalization of medical human resources between cities in the province in the short term.

基于2012年泰尔指数均值计算，其下降幅度约为18.5%。模型（3）和（4）的估计结果为负但不显著，这表明短期内实施HMS可能不会显著促进省内城市间医疗人力资源的均等化。

Additionally, the Tobit model estimation results in Table .

此外，表中的Tobit模型估计结果。

confirm the findings of TWFE. Hypothesis 1 is supported partially.

确认了TWFE的发现。假设1得到了部分支持。

Table 3 Effect of the HMS on the equalization between cities.

表3 HMS对城市间均衡的影响。

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Table 4 The results of Tobit model.

表4：Tobit模型的结果。

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In the quest for equitable distribution of medical human resources, the immediate impact of policy changes is often less noticeable due to the complexities inherent in policy formulation and the supply dynamics of medical human resources. The HMS, acting as a strategic framework for talent distribution, places a strong emphasis on nurturing medical personnel at the grassroots level by offering a comprehensive range of support measures, including training opportunities, talent development programs, and expert guidance.

在追求医疗人力资源的公平分配过程中，由于政策制定的复杂性和医疗人力资源供给动态的相互作用，政策变化的直接影响往往不太明显。HMS作为人才分配的战略框架，通过提供包括培训机会、人才培养计划和专家指导在内的一系列支持措施，高度重视基层医疗人员的培养。

However, the role of the HMS is more about fostering an environment that encourages long-term growth rather than providing immediate, tangible outcomes. Unlike the direct fiscal investment in physical resources, the enhancement of medical human resources at the grassroots level is a policy-driven process that requires time to bear fruit.

然而，HMS的作用更多是营造一个鼓励长期增长的环境，而不是提供立竿见影的具体成果。与对实物资源的直接财政投入不同，基层医疗人力资源的提升是一个政策驱动的过程，需要时间才能见到成效。

Moreover, the regional mobility of healthcare workers is often constrained by factors such as income levels, personal preferences, and career advancement opportunities, which typically draw them toward more developed urban areas.

此外，医疗工作者的地区流动性常常受到收入水平、个人偏好和职业发展机会等因素的限制，这些因素通常吸引他们前往较发达的城市地区。

. The absence of attractive incentives for working in underserved areas—characterized by inadequate compensation and limited opportunities for career progression—further discourages the redistribution of medical talent. Additionally, the concentration of medical educational resources in central cities exacerbates the maldistribution of skilled graduates, resulting in a bottleneck that hinders the supply of medical human resources to areas that are less developed.

缺乏在服务不足地区工作的吸引力激励措施——其特征是薪酬不足和职业发展机会有限——进一步阻碍了医疗人才的重新分配。此外，医学教育资源集中在中心城市，加剧了熟练毕业生的分布不均，导致欠发达地区医疗人力资源供应受阻的瓶颈。

The high qualification thresholds of the medical profession, which mandate extensive education and rigorous certification processes, limit the influx of new professionals into the field. Furthermore, the extended training period, often spanning several years to a decade, delays the availability of qualified personnel to underserved regions..

医疗行业资格门槛高，要求从业者接受广泛的教育和严格的认证过程，这限制了新从业者进入该领域。此外，漫长的培训期往往持续数年到十年不等，导致合格人员难以及时填补服务不足地区的空缺。

Event Study

事件研究

To test the above explanation further, we refer to the event study method and use Eq. (

为了进一步测试上述解释，我们参考事件研究方法并使用公式 (

) to estimate the dynamic effect of the implementation of the HMS on the equalization between cities in the province. Figure

）来估计实施HMS对省内城市间均等化的动态影响。图

reports the change of the coefficient of the variable according to Eq. (

根据公式( 报告了变量系数的变化情况。

) with time (confidence interval is 95%). The results show that for the Theil bed index, after the implementation of the HMS, it can respond immediately in the current period, and the level of equalization of medical material resources between cities in the province has been improved to a certain extent.

）随时间变化（置信区间为95%）。结果表明，对于Theil床位指数，在实施HMS后，当期就能立即作出反应，省内城市间医疗物质资源的均衡化水平在一定程度上得到了提升。

This influence has been declining until the third year after the implementation of the policy and then is not significant. However, the Theil doctor index is not significant in the current period and the following year but has a certain degree of influence from the second year after its implementation, and it continues until the fourth year.

政策实施后这一影响在第三年呈现下降趋势，之后不再显著。而泰尔医生指数当期和第二年并不显著，但从第二年开始产生一定的影响，一直持续到第四年。

It is further verified that compared with medical material resources, it might be difficult for medical human resources to adjust quickly to improve equalization levels within provinces..

进一步印证了与医疗物资资源相比，医疗人力资源可能难以快速调整以提升省内均衡化水平。

Fig. 2

图2

Dynamic effects of the HMS on the equalization of medical resource supply.

HMS对医疗资源供应均等化的动态影响。

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Robustness tests

稳健性测试

Parallel trend test

平行趋势检验

An important assumption of the DID method is that there is the common trend in the equalization indicators between the provinces (treatment group) that have implemented the HMS and the provinces (control group) that have not yet implemented the HMS. We can also employ Eq. (

DID 方法的一个重要假设是，在已实施 HMS 的省份（处理组）和尚未实施 HMS 的省份（对照组）之间的均衡指标存在共同趋势。我们还可以使用公式 (

) to test the common trend hypothesis. As shown in Fig.

）来检验共同趋势假设。如图所示。

, the various independent variables before the implementation of the HMS do not exhibit statistical significance at the 5% significance level. This observation suggests that there is no substantial disparity in the equalization indicators, thus satisfying the assumption of the common trend.

，实施HMS之前，各个自变量在5%的显著性水平上均未表现出统计显著性。这一观察结果表明均衡指标之间不存在显著差异，从而满足了共同趋势假设。

Placebo test

安慰剂测试

To ensure that our method accurately captures the effect driven by the HMS rather than some confounders, we conduct two placebo tests. First, assuming that the HMS took place 2 years before the actual time point, observe whether the implementation of the virtual HMS still significantly impacts the relevant equalization indicators.

为了确保我们的方法准确捕捉到由HMS驱动的影响，而不是某些混杂因素，我们进行了两项安慰剂测试。首先，假设HMS在实际时间点的两年前发生，观察虚拟HMS的实施是否仍然对相关的均等化指标产生显著影响。

If it is not significant, the influence of pre-event trends and confounders can be somewhat eliminated. The results are shown in Table .

如果它不显著，那么可以一定程度上消除事件前趋势和混杂因素的影响。结果见表。

, with no significant results. The placebo test once again provides evidence that the significance of relevant indicators of equalization is not due to the influence of pre-event trends or other accompanying policies.

，但没有显著结果。安慰剂测试再次证明均衡的相关指标的显著性不是因为受事件发生前的趋势或其他附带政策的影响。

Table 5 Advance the implementation points of the HMS in each province by 2 years.

表5 将各省HMS的实施点提前2年。

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Second, we give each province a pseudo-treated year when the HMS began, which is randomly selected, instead of the actual year. The regression coefficients are estimated repeatedly 500 times. The placebo plot in Fig.

其次，我们给每个省份一个伪处理年份，即HMS开始的时间，这个年份是随机选择的，而不是实际的年份。回归系数被重复估计500次。图中的安慰剂图（Placebo plot）显示了结果。

demonstrates that the average value of the estimated coefficients for 500 regressions is close to 0. In contrast, the coefficient in the baseline regression model, denoted by the dotted line on the left, is statistically significant and deviates from the placebo coefficients. The placebo test verifies that the results of the baseline regression model are not due to unobserved confounder factors..

表明500次回归中估计系数的平均值接近于0。相比之下，基准回归模型中的系数（左侧虚线所示）在统计上显著，并且与安慰剂系数存在偏差。安慰剂检验验证了基准回归模型的结果并非由未观察到的混杂因素所致。

Fig. 3

图 3

Placebo test. This figure depicts the distribution of estimated coefficients and corresponding

安慰剂测试。该图描述了估计系数的分布及其相应的

values for 500 pseudo-treated samples. The X-axis depicts the estimated pseudo-treated coefficients. The Y-axis depicts the distribution density and

500个伪处理样本的值。X轴表示估计的伪处理系数。Y轴表示分布密度。

values. The vertical dashed line depicts the actual treated effect of − 0.009 for Bed_bc. The horizontal dashed line depicts the 10% significant level. As illustrated in the figure, the estimated coefficients are predominantly near zero, and the majority of estimated values have

值。垂直虚线表示 Bed_bc 的实际处理效应为 -0.009。水平虚线表示 10% 的显著性水平。如图所示，估计系数大多接近于零，大多数估计值具有

values greater than 0.1 (not significant at the 10% level).

大于 0.1 的值（在 10% 水平上不显著）。

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Measurement of equalization

均衡度测量

To avoid the error caused by a single equalization index measurement, the Theil-L index and coefficient of variation (CV) are further considered to replace the explained variables for the baseline regression model. The Theil-L index, weighted by population proportion, is more sensitive to the change of lower resources, and the calculation method of Eq. (.

为了避免单一均衡化指数测量造成的误差，进一步考虑采用Theil-L指数和变异系数（CV）来替代基准回归模型中的被解释变量。Theil-L指数按人口比例加权，对较低资源的变化更为敏感，其计算方法见公式（。

) is adopted.

）被采纳。

$$Theil_{i}^{L} = \mathop \sum \limits_{j}^{N} \left( {\frac{{P_{ij} }}{{P_{i} }}} \right)\log \left( {{{\frac{{P_{ij} }}{{P_{i} }}} \mathord{\left/ {\vphantom {{\frac{{P_{ij} }}{{P_{i} }}} {\frac{{Y_{ij} }}{{Y_{i} }}}}} \right. \kern-0pt} {\frac{{Y_{ij} }}{{Y_{i} }}}}} \right)$$

$$Theil_{i}^{L} = \sum\limits_{j}^{N} \left( \frac{P_{ij}}{P_{i}} \right) \log \left( \frac{\frac{P_{ij}}{P_{i}}}{\frac{Y_{ij}}{Y_{i}}} \right)$$

(4)

where

其中

$Y_{ij}$

denotes the medical resource supply of the city

表示城市的医疗资源供应

$j$

in the province

在省内

$i$

, and

，以及

$Y_{i}$

denotes the medical resource supply of the province

表示该省的医疗资源供应

$i$

。

$P_{ij}$

is the population of the city

城市的人口是

$j$

in the province

在省内

$i$

, and

，以及

$P_{i}$

is the population of the province

是该省的人口数量

$i$

。

However, the Theil-T and Theil-L indices are sensitive to changes in the upper and lower layers, but insensitive to changes in the middle level. The CV can compensate for this issue. CV is used to calculate the equalization as follows.

然而，Theil-T 和 Theil-L 指数对上下层的变化敏感，但对中间层的变化不敏感。CV 可以弥补这一问题。CV 用于计算均衡性，如下所示。

$$CV_{i} = \frac{{\sigma_{i} }}{{\mu_{i} }}$$

(5)

where

其中

$\sigma_{i}$

denotes the variance of medical resources between cities in the province

表示该省城市间医疗资源的差异性

$i$

。

$\mu_{i}$

is the average level of medical resources supply in the province

是该省医疗资源供应的平均水平

$i$

。

The results of Theil-L and CV are consistent with the baseline results (Table

Theil-L和CV的结果与基线结果一致（表

）。

Table 6 Different equalization indicators.

表6 不同的均衡指标。

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Factors influencing the equalization effect

影响均衡效应的因素

Supply abundance

供给充足

We analyze the impact of the supply level of medical resources on equalization between cities in the province. We take 2012, the earliest implementation of the HMS, as the baseline year. According to the median of the number of beds and doctors per 1000 people, two sub-samples with high and low relative supply are generated.

我们分析了医疗资源供给水平对省内城市间均等化的影响。以2012年（HMS最早实施的一年）为基线年份，根据每千人床位数和医生数的中位数，生成了高、低相对供给的两个子样本。

The results (Table .

结果（表。

) show that after the implementation of the HMS in provinces with high material resources and high human supply levels, the effect of equalization is significant. In contrast, that in provinces with low material resources and low human supply levels is not significant. The coefficient differences of policy effect are 0.0159 and 0.0139, respectively.

）表明在物质资源丰富、人力资源供给水平高的省份实施HMS后，均等化效果显著；而在物质资源匮乏、人力资源供给水平低的省份则不显著，政策效果的系数差异分别为0.0159和0.0139。

The coefficient differences between groups are significant, indicating that the HMS has the stronger equalization effect in the province with the high supply level. Thus, Hypothesis 2 is supported..

组间系数差异显著，表明在供应水平高的省份，HMS具有更强的均衡效果。因此，支持假设2。

Table 7 The impact of the HMS on the equalization between cities (high supply vs. low supply).

表7 HMS对城市间均衡的影响（高供给与低供给）。

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Demand intensity

需求强度

According to the calculation method of the China Health Statistical Yearbook, Daily Visits Per Doctor in Hospital is equal to the number of visits per year divided by the average number of doctors and then divided by 251 (the number of working days per year). According to the affiliation of the health department, the general hospitals are divided into five levels: hospital of the National Health Commission, province hospital, hospital of the city at the prefecture, hospital of the city at the country level, and country hospital.

根据《中国卫生统计年鉴》的计算方法，医院医生日均诊疗人次等于年诊疗人次除以医生平均人数再除以251（每年工作日天数）。按卫生部门隶属关系，综合医院分为五个层级：卫健委直属医院、省级医院、地级市医院、县级市医院和县医院。

Hospitals with higher affiliated levels usually have higher medical quality. Therefore, we employ the ratio of the Daily Visits Per Doctor of provincial hospitals to the Daily Visits Per Doctor of county hospitals to measure the demand for high-level hospitals. We also take 2012, the earliest implementation of the HMS, as the baseline year.

具有较高隶属级别的医院通常医疗质量较高。因此，我们采用省级医院每位医生的日均接诊量与县级医院每位医生的日均接诊量之比，来衡量对高级别医院的需求。我们还以2012年（HMS最早实施的年份）作为基准年。

The results (Table .

结果（表。

) show that after the implementation of the HMS in provinces with the higher demand for high-level hospitals, the effect of equalization is more significant. Hypothesis 3 is supported.

）结果表明，在对高水平医院需求较高的省份实施HMS后，均等化效果更为显著。假设3得到支持。

Table 8 Effect of the HMS on the equalization between cities (high demand vs. low demand).

表8 HMS对城市间均衡的影响（高需求与低需求）。

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Economic imbalance

经济失衡

We further investigate the impact of the HMS on the equalization between cities in provinces with unbalanced economies. Similarly, 2012, the first year of the HMS, is taken as the baseline year, and two sub-samples of relative economic imbalance and relative economic balance were generated according to the median of the index of economic imbalance (.

我们进一步考察了 HMS 对省内经济发展不均衡城市间均等化的影响。同样地，将 HMS 政策实施的第一年 2012 年作为基准年，并依据经济失衡指数的中位数生成相对经济失衡与相对经济均衡两个子样本。

TGDP

真实GDP

) between cities in the province. According to the baseline regression model, get the regression results in Table

) 省内城市之间。根据基准回归模型，得到表中的回归结果。

. The results show that the coefficient differences of policy effects are 0.0095 and 0.0311, respectively, and there are significant differences between groups. Hypothesis 4 is supported.

结果表明，政策效应的系数差异分别为0.0095和0.0311，组间存在显著差异，假设4得到支持。

Table 9 Effect of the HMS on the equalization between cities (economic imbalance vs. economic balance).

表9 HMS对城市间均衡的影响（经济失衡与经济平衡）。

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Conclusion and discussion

结论与讨论

This study is, to our knowledge, the first to examine the impact of the HMS on the supply side of medical resources at the provincial level. Our empirical analysis revealed that the HMS has significantly contributed to the equalization of medical material resources within provinces. However, it has not significantly affected the equalization of medical human resources.

据我们所知，本研究是首个在省级层面上考察HMS对医疗资源供给方影响的研究。我们的实证分析表明，HMS显著促进了省内医疗物质资源的均等化，但对医疗人力资源的均等化没有显著影响。

The robustness of our results was confirmed through parallel trend tests, placebo tests, and the substitution of different equalization measures. At the micro-level, Lu et al..

通过平行趋势检验、安慰剂检验以及替换不同的均等化措施，验证了我们结果的稳健性。在微观层面，卢等人。。

conducted an analysis focused on Beijing, assessing the equity and accessibility of medical resources before and after the HMS using a three-stage two-step floating catchment area method. Their findings indicated that the HMS exacerbated the inequality of resource accessibility among towns and streets.

运用三阶段两步移动搜寻法对北京市进行分析，评估医联体政策实施前后医疗资源的公平性与可及性变化。研究结果表明，医联体政策加剧了乡镇街道之间资源可及性的不平等。

However, our study takes a macro perspective to analyze intra-provincial disparities in medical resource distribution across the country. Although our conclusion is not comparable to the findings of Lu et al..

然而，我们的研究从宏观角度分析了全国各省内部医疗资源分布的差异。尽管我们的结论与Lu等人研究结果不具有可比性。

, our study contributes to the existing literature by providing insights into the broader implications of the HMS on resource distribution. Anand et al. have shown that the inequality in doctor distribution is significant, primarily due to within-province disparities rather than between-province differences, which greatly impacts health outcome inequalities.

，我们的研究通过提供对 HMS 在资源分配上的更广泛影响的见解，为现有文献做出了贡献。Anand 等人已经表明，医生分布的不平等现象是显著的，这主要是由于省内差异而非省间差异造成的，这对健康结果的不平等产生了重大影响。

. Our findings reveal the limited effect of the implementation of the HMS on the equalization of medical human resources within provinces. A plausible explanation is that transferring funds from developed regions and investing in material resources in underdeveloped areas is relatively straightforward, which promotes medical material resource equalization.

我们的研究结果表明，实施卫生系统管理（HMS）对省内医疗人力资源均等化的效果有限。一个可能的解释是，将发达地区的资金转移到欠发达地区并投资于物质资源相对容易，这促进了医疗物质资源的均等化。

. In contrast, the supply of human resources is influenced by various factors, such as revenue, the economic status of the cities, the limitations of medical staff’s professional qualifications, lengthy training periods, and hospital personnel turnover, which often fail to rapidly enhance the supply level in underdeveloped areas.

相比之下，人力资源的供给受到多种因素的影响，如收入、城市经济状况、医务人员专业资格限制、培训周期长以及医院人员流动等，往往难以迅速提升欠发达地区的供给水平。

，

. Consequently, it is still challenging for the HMS to promote the equalization of medical human resources among cities. A study from Shanghai has also revealed that while there has been an improvement in medical material resources, disparities among doctors persist, indicating that the recruitment and education of healthcare personnel is an ongoing endeavor necessary to bridge the gap in medical resource distribution between center city and sub-city.

因此，HMS在促进城市间医疗人力资源的均等化方面仍然面临挑战。上海的一项研究也显示，虽然医疗物质资源有所改善，但医生之间的差异仍然存在，这表明招募和培养医务人员是一项持续的任务，对于弥合中心城区与郊区之间医疗资源分配的差距至关重要。

。

We found that in the provinces with higher levels of medical resource supply, the HMS’s effect on promoting equalization was more significant. Previous studies suggest that a higher supply of overall medical service resources may indicate that the government is capable of allocating medical resources to underdeveloped areas.

我们发现在医疗资源供给水平较高的省份，HMS对促进均等化的作用更显著。以往研究指出，总体医疗服务资源供给越多可能意味着政府有能力将医疗资源分配到欠发达地区。

，

. In terms of hospital size regulation, in provinces where medical resources are abundant and overly concentrated, the HMS may exert a stronger influence in guiding and encouraging medical institutions to plan their scale rationally and prevent indiscriminate expansion. Additionally, the HMS’s impact on promoting the equalization of medical resources is more pronounced in areas with a higher demand for high-level hospitals.

在医院规模监管方面，在医疗资源丰富且过度集中的省份，HMS可能在引导和鼓励医疗机构合理规划规模、防止盲目扩张方面发挥更强的作用。此外，HMS在促进医疗资源均等化方面的影响在对高等级医院需求较高的地区更为显著。

The medical demand-side pressures suggest a stronger HMS reform motivation in provinces with higher demand for high-level medical resources. Our findings provide suggestive evidence that demand-side factors might drive the HMS reform on the supply side..

医疗需求侧的压力表明，在对高等级医疗资源需求较高的省份，HMS改革的动力更强。我们的研究结果提供了暗示性证据，表明需求侧因素可能会推动供给侧的HMS改革。

Moreover, the HMS promoted equalizing medical resources in provinces with relatively unbalanced economic development. Economic development is the primary material guarantee for providing medical services. In the process of economic development, where economic factors are concentrated, medical resources are also highly concentrated in space, which leads to regional inequality of medical resources.

此外，HMS推动了经济发展相对不平衡省份的医疗资源均衡化。经济发展是提供医疗服务的主要物质保障。在经济发展过程中，经济要素集中的地方，医疗资源也在空间上高度集中，这导致了医疗资源的区域不平等。

Implementing the HMS promoted equalizing medical resource supply in provinces with unbalanced economic development, which reflects the characteristics of the HMS promoting fairness. An effective strategy to reduce medical resource inequality involves creating a flexible tax-sharing framework, which helps balance local governments’ fiscal capacities, providing those with lower self-sufficiency access to additional financial resources.

实施HMS促进了经济发展不平衡省份的医疗资源供应均衡化，这体现了HMS推动公平性的特点。减少医疗资源不平等的有效策略包括建立灵活的税收共享框架，这有助于平衡地方政府的财政能力，为自给率较低的地区提供额外的财政资源支持。

. Decentralization encompasses several dimensions: policy, political, and fiscal

去中心化包含多个维度：政策、政治和财政

，

. Concurrently, the promotion of medical resource equity through the HMS has been accompanied by a redistribution of financial responsibilities. The central government requires provincial governments to further rationalize the financial affairs and expenditure responsibilities of sub-provincial governments within the medical and health sector.

同时，通过 HMS 推进医疗资源公平化伴随着财政责任的重新分配。中央政府要求省级政府进一步合理化省以下政府在医疗卫生领域的财政事务和支出责任。

The responsibilities of provincial governments in advancing the equalization of medical services have been clarified, and transfer payments to underprivileged areas within the region have been increased. The HMS facilitates the transfer of basic medical and health service expenditure responsibilities to higher levels of government where appropriate, thereby preventing an excessive burden on grassroots government expenditures..

明确了省级政府在推进医疗服务均等化方面的责任，并增加了对区域内欠发达地区的转移支付。卫生部通过将基本医疗和卫生服务支出责任适当转移到更高层级的政府，从而避免基层政府支出负担过重。

A significant policy implication arising from this study, and a key direction for future research, is the need to enhance the effectiveness of HMS policies in promoting a more equitable distribution of medical human resources. These resources are crucial for the operational framework of medical institutions and are a key determinant of their ability to deliver healthcare services.

本研究得出的一项重要政策含义以及未来研究的一个关键方向是，需要提高卫生人力政策在促进医疗人力资源更公平分配方面的有效性。这些资源对于医疗机构的运作框架至关重要，也是决定其提供医疗服务能力的关键因素。

Our findings suggest that future HMS policies should prioritize strategies to redirect medical human resources toward less developed areas. Future research adopting a micro-level approach, by focusing on individual physicians, could provide valuable insights into how to achieve a more balanced distribution of medical human resources.

我们的研究结果表明，未来的卫生管理政策应优先考虑将医疗人力资源重新导向欠发达地区的策略。未来的研究采用微观层面的方法，通过关注个别医生，可以为如何实现医疗人力资源的更均衡分布提供有价值的见解。

An in-depth exploration of personal preferences, career aspirations, and the specific push-pull factors influencing the geographic distribution of medical professionals could significantly enhance our understanding of this complex phenomenon..

深入探讨个人偏好、职业抱负以及影响医疗专业人员地域分布的具体推拉因素，可以显著增强我们对这一复杂现象的理解。

With the rapid development of information and communication technology (ICT), digital health technologies such as remote healthcare have been rapidly disseminated worldwide. These technologies not only enhance the accessibility and quality of medical services but also play a significant role in optimizing the allocation of medical resources and promoting healthcare equity.

随着信息通信技术（ICT）的快速发展，远程医疗等数字健康技术在世界范围内迅速普及。这些技术不仅提升了医疗服务的可及性和质量，还在优化医疗资源配置和促进医疗公平性方面发挥了重要作用。

Future research can systematically analyze the mechanisms and equity effects of remote healthcare and other information technologies in promoting the equal distribution of medical resources from a spatial equity perspective. It is important to explore the role of digital health technologies in reducing patient mobility across regions, shortening medical consultation times, and lowering healthcare costs, as well as its potential to enhance healthcare equity for vulnerable groups, such as the older people and people with disabilities..

未来研究可以系统分析远程医疗和其他信息技术在促进医疗资源均等化分布中的机制与公平效应，从空间公平的视角出发。重要的是探索数字健康技术在减少患者跨区域流动、缩短就医时间、降低医疗成本方面的作用，以及其在提升老年人和残疾人等脆弱群体医疗公平性方面的潜力。

This study had several potential limitations. First, due to the limitation of sample size, there is only one province that has never been treated during the sample period. Because of the heterogeneous treatment effect, our estimate of TWFE may be biased

本研究存在若干潜在局限性。首先，由于样本量的限制，在样本期间内只有一个省份从未接受过处理。由于处理效应的异质性，我们对TWFE的估计可能存在偏差。

，

. Second, due to data limitations at the city level, we measure medical human and material resources solely by the number of doctors and beds, respectively, which may not represent the reality of resource distribution. We were only able to measure the equalization of medical resources among cities within the province, without being able to analyze it at a more granular district level.

其次，由于城市层面的数据限制，我们仅分别通过医生和床位的数量来衡量医疗人力资源和物力资源，这可能无法准确反映资源分布的实际情况。我们只能衡量省内城市间的医疗资源均等化情况，而无法在更细致的区县层面进行分析。

This restriction limited our ability to capture potential variations and nuances within the province. Third, it is worth noting that the quality of the medical resource supply is also an important aspect deserving consideration. However, this paper focuses solely on quantity due to the challenge of measuring the distribution of medical quality within provinces.

这一限制影响了我们捕捉省内潜在变化和细微差别的能力。第三，值得注意的是，医疗资源供应的质量也是一个值得考虑的重要方面。然而，由于衡量省内医疗质量分布的挑战性，本文仅聚焦于数量层面。

Fourth, the influencing factors of macro-level changes in the context of medical resource equalization are inherently complex. Therefore, the evidence presented in this study regarding the underlying factors is suggestive. In future research, gathering micro-level evidence and conducting more detailed investigations would be valuable..

第四，宏观水平上医疗资源均等化的背景变化影响因素本身较为复杂，因此本研究针对潜在影响因素的证据具有提示性。在未来的研究中，收集微观层面的证据并进行更细致的分析将是有价值的。

To sum up, this study provided empirical evidence of the impact of the HMS on medical resource allocation. These findings have important policy implications, particularly for addressing the unequal medical resource allocation in China. The role of the government in achieving equal access to medical services is a crucial topic in health economics and public management.

总之，本研究提供了关于HMS对医疗资源分配影响的实证证据。这些发现具有重要的政策意义，特别是对于解决中国医疗资源分配不平等问题。政府在实现医疗服务平等获取方面的作用是卫生经济学和公共管理中的关键议题。

The study’s findings and the policy practices in China have the potential to promote the realization of universal health coverage..

该研究的发现和中国的政策实践有助于推动实现全民健康覆盖。

Data availability

数据可用性

The main data used in this study are publicly available and were obtained from the National Bureau of Statistics of the People’s Republic of China website (

本研究使用的主要数据为公开数据，获取自中华人民共和国国家统计局网站 (

http://www.stats.gov.cn/

). Policy data are from public websites, including the official health department sites of various Chinese provinces and Peking University Law’s Local Laws and Regulations Database (

）。政策数据来自公共网站，包括中国各省卫生健康委员会官方网站和北京大学法律信息网地方法律法规数据库（

https://www.pkulaw.com/

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Funding

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This research was supported by the National Social Science Foundation of China (Number: 20AGL034).

本研究得到了中国国家社会科学基金（编号：20AGL034）的支持。

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Center for Social Science Survey and Data, Tianjin University, 92 Weijin Road, Nankai District, Tianjin, 300072, China

中国天津市南开区卫津路92号天津大学社会科学调查与数据中心，邮编300072

Liping Fu, Ruizhen Wang & Yu Dong

傅丽萍、王瑞珍、董宇

College of Management and Economics, Tianjin University, Tianjin, 300072, China

中国天津市天津大学管理与经济学院，邮编300072

Liping Fu, Ruizhen Wang & Yu Dong

傅丽萍、王瑞珍、董宇

College of Politics and Public Administration, Qinghai Minzu University, Qinghai, 810007, China

青海民族大学政治与公共管理学院，青海，810007，中国

Liping Fu

傅立平

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傅立平

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王瑞珍

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Contributions

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L.F.: Supervision, conceptualization, funding acquisition, writing-review and editing, methodology. R.W.: Writing-original draft, formal analysis. Y.D.: Data collection, writing-original draft. All authors have read and agreed to the published version of the manuscript.

L.F.：监督、概念化、资金获取、撰写审阅与编辑、方法论。R.W.：撰写初稿、正式分析。Y.D.：数据收集、撰写初稿。所有作者均已阅读并同意发表的手稿版本。

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王瑞珍

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Fu, L., Wang, R. & Dong, Y. The impact of the hierarchical medical system on medical resource allocation in China.

傅磊、王荣、董毅。中国分级医疗体系对医疗资源配置的影响。