To better address the problems and challenges facing primary health care services in China, China's National Health Commission and the Gates Foundation have been collaborated to implement primary health care projects in areas such as Shanxi Province, Hubei Province, and part of the rural areas of Henan Province from 2017 to 2022. The overall goal of the project is to explore an effective model for basic health care services and to contribute to health poverty alleviation, which will enhance experience sharing within China and benefit other developing countries.

To summarize the experience of implementing person-centered integrated health management project in rural populations with priority diseases, represented by hypertension and diabetes.

The collection of information and data for the person-centered integrated health management project encompassed multiple sources, including hospital information system, statistical reporting information, basic public health information system, qualitative interviews, patient surveys, physician surveys and quality surveys of medical records. Descriptive statistical analysis as well as before-and-after comparisons were used as the main evaluation methods.

The proportion of patients with hypertension and diabetes under standardized management increased steadily, the average hospitalization cost of inpatients decreased, with a gradual increase in healthy living behaviors and a significant improvement medication adherence. In terms of health outcomes, the control rate of hypertension improved significantly but the control rate for blood glucose did not change significantly.

The service concept and capacity of person-centered integrated health management for priority diseases have been significantly improved. The relevant measures have been transformed into policies to be promoted and implemented in the project areas. Various types of experts are the key factors in promoting the implementation of the project, the sustainability of the measures needs to be maintained.