Reforming primary care in China
In this step we explore in more detail some of the key choices regarding the design or architecture of health systems, discussed in the previous step, focusing on the Chinese experience.
This case looks at the experience of Primary Care Reform (PCR) in China, specifically in the city of Wuhan. Please read the summary below and watch the short video above describing this case.
As you will see from the previous step, China faces numerous challenges, one of which is the need to reduce demand for hospital based care and achieve more effective co-ordination with primary care services. There are significant policy and institutional obstacles to this coordination, with primary care managed and funded separately from hospitals. However, there are also instances where PCR has made progress. One example of this, the focus of our case is the ‘Fifth Hospital’, in the Han Yang district of the city of Wuhan.
With a population of 10.6 million, Wuhan is one of China’s largest cities, located in the central plains of China on the Yangtze River (Hubei province). By Chinese standards the Wuhan healthcare system is highly developed. The number of practicing physicians per 10,000 resident population is 31, compared to an average of 16.6 for China as a whole. The same measure for registered nurses and midwives is 42.6 compared to an average of 16.6. Despite marked improvements in resources and the quality of provision, primary healthcare services in Wuhan struggle with many of the same challenges that face those of China more widely. For a variety of reasons the demand for hospital based acute care has continued to rise, leading to over-crowding in the leading tertiary centres and rising costs. The cost of hospital referrals, for example is 231 RMB, compared to 62 RMB for community centre referral, with similar differences for inpatient services (9440 RMB for hospitals compared to 1870 RMB for community centres).
To address this, since 2008, the Wuhan city administration has embarked on a number of reforms of primary care which have achieved national recognition. Central to these reforms is the development of ‘medical alliances’. These alliances seek to achieve greater integration between large tertiary hospitals and community healthcare services to promote more effective upward and downward referrals.
A notable example of this alliance model is Wuhan’s Fifth Hospital ‘Medical Treatment Combination’. The Fifth Hospital is one of seven large tertiary hospitals in Wuhan, attached to a local university. As a tertiary centre it has 42 specialist departments and 1229 staff (including 343 doctors and 551 nurses). Since 2008, the Fifth Hospital has taken responsibility for the direct management of six community health centres (with over 400 beds and 426 staff) in the same geographical area (Han Yang district). Through what is colloquially known as the ‘Hospital together’ or ‘six in one’ model, the management and strategic planning of human resources, services and estates of primary and acute services are brought under a single entity (the medical alliance). While the main tertiary hospital (Fifth) and community health services retain separate legal identities, the aim is to make them work more closely together.
According to the Director, the main goal of the Fifth Hospital medical alliance is to ‘keep the treatment of simple diseases at community level and focus the tertiary hospital on more complex cases’. Typically a community centre will include a number of family doctor teams consisting of a GP, nurse, assistant and public health worker. These teams work closely with their local communities to build trust and act as gatekeepers, promoting upward referral to the main tertiary hospital in the most demanding cases. The Centres also handle a large number of downward (outpatient) referrals for rehabilitation, especially focused on traditional Chinese medicine.
Perhaps the most significant development is the facility for patients to access various treatments at the centre, close to their community, without having to travel to the main tertiary hospital. This has been achieved through investments in technical equipment and information systems, providing remote consultations and access to patient records (including x ray imaging). It is also supported by a mandatory system of ‘regular tour visits’ to the primary care centres by specialist doctors from the tertiary hospital. Typically 2-3 doctors visit each centre daily assisting with a variety of diagnoses and treatments.
The Wuhan city administration has made significant financial investments to support this initiative. Incentive payments have been used to assist with the recruitment of GPs to work in the community centres. Recruitment and retention has also been helped by the reputation of the Fifth hospital, which is attractive to many new graduates. Average annual salaries for doctors in community centres have risen from RNB 21600 in 2007, to RNB 78650 in 2015 and are now only slightly lower than for hospital based doctors. Substantial investments have also been made in the training of GPs, with the development of a three year GP resident training programme in 2013, in partnership with Jianghang University.
Although the results of formal evaluations of this initiative are still pending, early signs are promising. Feedback from patients has been positive so far. Many patients have found community based services more convenient than the tertiary hospital and have built up trusting relationships with their GP teams. The volume of patients treated in the six community centres has also increased from 1260 in 2007 to 2338 in 2015, helping to manage demand for services delivered by the main tertiary hospital. For this reason Wuhan’s medical alliance is being hailed as a success story, with plans to make further investments in future.
However, despite these achievements, there are significant challenges to the sustainability of this model. One difficulty arises from the continued policy of double charging of patients for the use of tertiary (first tier) and primary services, in some cases reducing the incentive to enter the community centres as an outpatient. There is also the recurring challenge of persuading patients to use community centres. As a result, demand for hospital care has continued to rise with knock on effects for the time available to specialist doctors to work externally (on a rotating basis) in the community centres. These (and other) challenges mean that the Fifth Hospital ‘medical alliance’ experiment has some way to go before it reaches its full potential. Much will also depend on the political climate and how far city administrators are willing and able to support this initiative.
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