Harry HX Wang and Sian M Griffiths: A primary care oriented approach to pursue population health in China

From Healthy China 2020 to Healthy China 2030

Seven decades ago, China’s healthcare was characterised by barefoot doctors who demonstrated the contribution of primary care to improved population health. Subsequent reform, however, restructured the healthcare delivery model to focus on providing curative care in a market driven system as opposed to spending on preventive care. Despite progress made through recent policies on expanding insurance coverage, the scope of insurance packages is limited to guarantee only the minimum health needs. [1] In the absence of gatekeeping in primary care, the ability to pay impacts on people’s healthcare utilisation [2] The escalation of out-of-pocket payments often results from fragmented care and multiple hospital visits due to patients’ preferential use of secondary over primary care. [3] Since long-term conditions and multimorbidity have become the greatest threats to population health, there is an urgent need to re-establish strong primary care with equitable health care service delivery. [3]

As in other parts of the world, emerging challenges to the pursuit of population health include, but are not limited to, the rapidly ageing population, unhealthy lifestyles, psychosocial factors, environmental hazards such as climate change and air pollution, and health transitions. These have profound effects on the demand for more and better healthcare. The “Healthy China 2020″ plan, first introduced in 2007, has been part of the ongoing healthcare reform efforts.

One main goal has been to broaden equitable access to healthcare for all citizens and reduce the spread of chronic diseases by 2020. [4] A primary care framework, built upon urban community health centres (CHCs) and township health centres, is being introduced to encourage the delivery of safe, effective, convenient, and affordable basic care by general physicians (GPs) outside of hospitals. [5] Whilst the absolute number of urban and township health centres have exceeded that of hospitals (71,048 compared with 28,261), the total number of patients handled at the secondary care settings remained far in excess of those at primary care level (1,568 million compared with 839 million) during the first half of 2016. [6] The underuse of primary care may have resulted from the lack of gatekeeping and referring systems so that people can bypass primary care and go straight to hospitals. The mistrust from the general public in primary care service provision may also play a role, and could be partially attributed to the disparity in medical education and training between GPs and specialists in China. Also, the poor capacity building and lack of resources to cover both preventive care and disease treatment in primary care settings have created barriers impeding the delivery of community-oriented care services on which poor experiences are reported from patients. [5]

In August 2016, President Xi announced a new plan—”Healthy China 2030,” which recognises the current challenges and prioritises the agenda for adopting a healthcare system that focuses more strongly on primary care to promote population health. [7] A consensus has been reached that the state of being healthy is an ultimate prerequisite for whole-person development and the symbol of prosperity in a well-off society. The plan proposes solutions to reinforce the provision of equitable primary care for all, to raise the quality of care at a grass-roots level, and to establish an integrated stepwise process following levels of care. This policy, building on the basic tenets of “Healthy China 2020,” continues to draw on the universal care model of the UK and to emphasise the role of GPs as gate keepers as well as the importance of prevention.

Innovations for primary care in “Healthy China 2030” include:

(i) Start with perspectives which take account of the wider determinants of health and emphasise the principle of prevention through promoting healthy lifestyles, optimising health services, enhancing health protection, building healthy environments and food safety, as well as developing health and wellbeing industry.

(ii) Take multi-sectorial approaches within government and create public-private partnerships to embed wellbeing viewpoints into all policies, with life-cycle thinking in place, to span across all aspects of population health, beginning with parental care and culminating in healthier ageing.

(iii) Extend universal health coverage and redress inequity in the distribution of healthcare resources to solve the health problems faced by women and children, the elderly, the disabled, floating populations, and lower-income groups.

(iv) Expand and ensure a competent primary care workforce by better incentivisation and support for GP education and training systems to meet the healthcare needs of the population.

(v) Reinforce the “six-in-one” primary care service package proposed in Healthy China 2020 by integrating prevention, treatment, protection, rehabilitation, education, and family planning through contracts placed between community residents and CHCs for GP-led team-based first-contact service, dual-referrals across levels of care, and innovative computerised health record platform.

Commitment to the strategic shift away from secondary care towards primary care echoes the recent World Bank and WHO calls to deepen health reforms in China. [8] The current bias towards hospital-centric and volume-driven care rather than improving population health outcomes at the primary care level needs to change, as annual expenditure could rise by 8.4% annually from 5 trillion RMB in 2014 to 15.8 trillion RMB by 2035. Accordingly, health spending would account for more than 9% of gross domestic product in 2035, up from 5.6% in 2014. [8] A high-quality and value-based service delivery system should therefore be able to reduce the direct economic costs from poor health related to irrational use of healthcare. Through describing the route map for long-term planning and sustainable strategic growth rather than short-term projects, “Healthy China 2030” would bring a shift in the world’s biggest and most complex healthcare reform away from focusing on episode-based curative care towards emphasising wellbeing outcomes with lower costs through re-strengthening primary care. The forthcoming visit to China (in December) for the fourth meeting of the China-UK High Level People to People (P2P) Dialogue by the Secretary of State for Health, Jeremy Hunt, will give further impetus to mutual leaning, and if Healthy 2030 succeeds we are expecting to see a primary care system that is uniquely Chinese but utilising acknowledged aspects of the UK system in the pursuit of population health, providing many opportunities for further collaboration.

Harry HX Wang, associate professor, School of Public Health, Sun Yat-Sen University, Guangzhou.
JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong.
General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow.

Sian M Griffiths, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong.
Institute of Global Health Innovation, Imperial College London. 

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.


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