In recent years, China has attached great importance to strengthening the development of general practitioner (GP) workforce and primary care service system. To innovate the incentive mechanism for GP training and employment and improve the training system for GPs, the government has also promulgated a series of policies and put forward major reform measures involving many aspects.
To analyze and evaluate the fairness of distribution of general practitioner (GP) resources in China, and to provide theoretical support for scientific and equitable allocation of GP resources.
Data were sourced from five volumes of China Health and Family Planning Statistical Yearbook (2017—2021), China Health Statistical Yearbook (2017—2021), and China Statistical Yearbook (2017—2021) in June 2022, including the number of GPs, the number of people registered as general medicine professionals, the number of people who obtained the General Practitioner Certificate after training, the number of GPs per 10 000 population, and the number of practicing (assistant) physicians in China, in each geographical division (eastern, central or western), and in each regionin, and the annual gross domestic product (GDP), gross regional product (GRP), and the year-end total population data of each region during 2016 and 2020. Additionally, the total land area of each region was extracted from the China ABC column on the website www.gov.cn. The Lorenz curve and the Gini coefficient were used to analyze the fairness in the distribution of GP resources. The Theil index was used to analyze differences in the distribution of GP resources in eastern, central and western China.
The number of GPs in China increased from 209 083 in 2016 to 408 820 in 2020, showing a growth rate 95.53%. In 2020, the proportion of GPs among all practicing (assistant) physicians reached 10.01% (408 820/4 085 689), and the number of GPs per 10 000 population was 2.90. The Gini coefficients measuring demographic, economic, and geographical distribution inequalities of GP resources were 0.235, 0.178, 0.722, respectively for 2016, 0.231, 0.170 and 0.726, respectively for 2017, 0.225, 0.161 and 0.729, respectively for 2018, 0.177, 0.147 and 0.714, respectively for 2019, and 0.157, 0.136, and 0.707, respectively, for 2020. Overall, the Lorenz curve measuring the inequality in the distribution of GP resources by demographics or economy had lower degree of curvature than that by geography. A reduction was found in Theil index measuring unequal demographic, economic or geographical distribution of GP resources in 2020 compared with that in 2016 (from 0.046 to 0.020; from 0.022 to 0.013; from 0.482 to 0.428) .
During the five years, the distribution of GP resources in China presented the following features: the number of GPs increased rapidly and became an important part of the workforce of practicing (assistant) physicians, the registration rate of GPs gradually increased, and the total GP resources showed a continuous growth, but the ratio of GPs per 10 000 population was still unsatisfactory, great inter-region differences existed in the distribution of GP resources, and the equity of the distribution of GP resources by geography was more unsatisfactory than by demographics or economy.
In China, the governance of public health by the public health committee, a grassroots mass autonomous organization, is a new approach managing public health services in primary care. Many regions are exploring governance models of public health by the public health committee, aiming to make it a key hub to realize the vertical connection and horizontal linkage grid management of grassroots communities.
To analyze the policy documents related to the construction of local public health committees of various regions in China using policy document analysis, so as to provide a reference for improving the primary-level public health governance system and governance capacity.
In March 2022, we searched policy documents related to the construction of public health committees on the official websites of the local governments and health commissions of eight sample regions (Beijing, Guangdong, Chongqing, Shandong, Anhui, Guizhou, Gansu, and Ningxia Hui Autonomous Region) in which village (residential) public health committees have been constructed using "public health committee" as the key search term. Through literature review and policy document analysis, an analytical framework for the governance system of the public health committee was constructed. Nvivo 11 Plus was used for word frequency and coding analyses of the included policy literature.
A total of 15 policy documents and 2 guidance manuals for the work of public health committees were ultimately included. Word frequency analysis showed that the five words, "hygiene" "public" "work" "committee" and "health", appeared most frequently, indicating that the selected policy literature conformed to the research theme. By using the analytical framework, the structural dimensions of the policy literature were determined, including four root nodes, namely, governance subjects, governance mechanisms, institutional guarantees, and capacity building, and 13 sub-nodes. There are 208 reference points for governance subjects, 48 reference points for governance mechanisms, 57 reference points for institutional guarantees, and 87 reference points for capacity building.
The local policy documents of the sample regions cover the contents of the four dimensions, but have different focuses. According to the framework in this study, further construction of the public health committee needs to set certain admission criteria with clear determination of rights and responsibilities for new committee members, establish an effective cooperation and communication mechanism, improve the system guarantee and provide financial and technical support.
The reimbursement of outpatient services is an essential part of the reform of medical insurance payment methods. With the comprehensive promotion of the reform on the medical insurance payment methods for inpatient services in China, the reform on insurance payment methods for outpatient services, such as capitation-based reimbursement and ambulatory patient groups (APG) point method, will gradually be put on the agenda.
To explore a capitation-based reimbursement scheme for chronic diseases applicable to Beijing based on an analysis of capitation-based reimbursement implemented in different countries and regions and the current situation of chronic disease management in Beijing, to provide a reference for implementing the capitation-based reimbursement reform for chronic diseases in Beijing.
This study used information related to essential medical services, reimbursement by health insurance, and essential public health service funds in Beijing's C and H districts. Then through an analysis of the information, the calculation method for capitation-based reimbursement standard for four common chronic diseases (hypertension, diabetes, coronary heart disease and stroke were selected in this study) applicable in the districts was designed to calculate the capitation-based reimbursement standard for major chronic diseases in primary outpatient clinics, providing a reference for promoting the capitation reform for chronic diseases in outpatient clinics.
By analyzing the above-mentioned information in 2017—2019, the capitation-based reimbursement standard was 4 693.11 yuan/person for hypertension, 6 597.70 yuan/person for diabetes, 5 644.46 yuan/person for coronary heart disease, and 6 437.78 yuan/person for stroke in H district calculated using the bottom-up costing, and was 4 884.18 yuan/person for hypertension, 5 960.63 yuan/person for diabetes, 3 733.93 yuan/person for coronary heart disease, and 3 886.66 yuan/person for stroke in C district calculated using the top-down estimating.
In calculating the capitation-based reimbursement standard, as different chronic disease patient groups have different outpatient costs, considering the equity of medical insurance reimbursement and the rationality of capitation-based reimbursement, it is necessary to adjust the risk of the benchmark capitation, and develop personalized service packages for different types and severity of chronic diseases. In the promotion of capitation payment for chronic disease patients, it is necessary to provide personalized essential medical service and public health service packages for patients with different chronic diseases, further improve the chronic disease management capacity of community health institutions to improve the contracting rate and establish an effective incentive and assessment mechanism for general practitioners to rationally allocate capitation balance.
Exploring the factors affecting health service utilization is of great significance for optimizing the allocation of health services. Health-related quality of life (HRQoL) focuses on individuals' subjective self-assessment of their current health status, and may affect their health-seeking behaviors, but there are few studies on the impact of HRQoL on health service utilization of rural residents in China.
To explore the relationship between HRQoL and health service utilization of rural residents in Ningxia Hui Autonomous Region, and to provide a reference for the development of relevant policies/plans, and for the optimization health services in rural areas.
Data were collected from the Health Survey of Rural Residents Families 2019 conducted in four sample counties of Ningxia (Haiyuan, Pengyang, Xiji, Yanchi) from July to August 2019, involving 9 310 cases (≥15 years) with complete key information (gender, age, HRQoL-related indicators, health service utilization indicators). Detailed data of the residents were extracted, including socio-economic and demographic characteristics, health services accessibility, prevalence of chronic diseases, HRQoL measured using European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) and utilization of health services. The effects of health state utility values and visual analog scale (VAS) score on outpatient and inpatient health service utilization were analyzed by binary Logistic regression.
The utilization rates of outpatient and inpatient health services of rural residents in Ningxia were 10.85% (1 010/9 310) and 18.86% (1 756/9 310), respectively. The mean health state utility values and mean VAS score of them were (0.965±0.090) and (69.97±17.84), respectively. Difference testing showed that residents with impaired self-care (in the EQ-5D-3L descriptive system) had higher rates of using outpatient health services〔OR (95%CI) =3.197 (2.633, 3.883), P<0.001〕and inpatient health services〔OR (95%CI) =4.802 (4.059, 5.681), P<0.001〕compared with those with impaired mobility, usual activities, or higher level of pain/discomfort or anxiety/depression. Binary Logistic regression analysis showed that after adjusting for various confounding factors, health state utility values and VAS score were associated with the use of outpatient and inpatient health services (P<0.05). Moreover, the prevalence of chronic diseases also significantly affect the utilization of outpatient and inpatient health services (P<0.05) .
HRQoL and the prevalence of chronic diseases were leading factors affecting the utilization of outpatient and inpatient services in Ningxia rural residents. As an independent predictive factor of residents' health service utilization, HRQoL can be used to assist in the evaluation and monitoring of health service quality and effect, and provide guidance for rational allocation of health resources.
With the increasing aging and the transformation of the disease spectrum of residents, there is increasing national attention to the development of Traditional Chinese Medicine (TCM) services. It is of great significant in better utilizing the proper value of TCM community services in the future to understand the current situation and influencing factors of TCM community services utilization.
To understand the current situation and influencing factors of TCM community services utilization among residents in the main urban areas of Chongqing from demander's perspective, so as to provide reference for the sustainable development of TCM community services.
On December 1, 2021, 23 community health service centers were selected by quota sampling method in proportion to the population in 9 central urban areas of Chongqing, and the residents in each community health service center and its surrounding communities by incidental sampling method were selected to conduct questionnaire surveys. The actual number of questionnaires distributed was 840 with 806 valid questionnaires and effective rate of 96.0%. Based on Anderson's health service utilization behavior analysis framework, the factors influencing individual service utilization behavior were summarized into three categories: tendency characteristics, enabling resources and demand factors. At the same time, the dimension of personal TCM culture was added. Binary Logistics regression was used to analyze the influence of the four dimensions on the utilization of TCM in the community.
The utilization rate of TCM community services among the surveyed residents was only 35.9% (289/806), 12 indicators in 4 dimensions were associated with the TCM community services utilization, including propensity characteristics (age, marital status), enabling resources (type of medical insurance, medical expenditure in the last 2 weeks, whether the institutions can meet the basic medical needs of families, whether institutions provide TCM services), demand factors (chronic diseases, self-perception of physical condition in 2 weeks, demand for TCM community services), personal TCM culture (TCM referral willingness, TCM culture trust level, community TCM cultural atmosphere) (P<0.05) .
There are multidimensional and multifactorial influences on the TCM community services utilization among residents. Therefore, targeted measures should be taken to promote residents' utilization of TCM community services.
The promotion of appropriate traditional Chinese medicine (TCM) techniques in primary care institutions is an important measure emphasizing the co-development of Chinese and western medicine, and enhancing the inheritance and development of TCM.
To analyze primary health workers'preferences for the use of appropriate TCM techniques, providing policy recommendations for the promotion and use of such techniques in primary healthcare institutions.
This questionnaire survey was conducted between July and August 2021. A discrete choice model with seven attributes and 18 choice sets obtained through the use of an efficient orthogonal design were used to develop the questionnaire used in the survey, and the questionnaire has three versions each version with evenly allocated six choice sets (including an opt-out option). Additionally, the three versions have a common general demographic part (sex, age, education level, professional title, etc.) and one common consistency test question. A randomized multistage stratified cluster sampling was used to select 319 health workers on duty on the survey day from a total of 23 primary healthcare institutions in three counties in eastern, central and western China (one county was extracted from each region), and each worker was required to complete one version of the questionnaire extracted sequentially by themselves. Two hundred and ninety-five cases who returned a questionnaire passing a consistency test were included for analysis, resulting in a response rate of 92.5%. Primary health workers' preferences for appropriate TCM techniques were analyzed using conditional Logit models and latent class models. Furthermore, the changes in utility of primary health workers due to attribute level changes were monetized using willingness to pay and presented accordingly.
The conditional Logit analysis showed that medical insurance, the average duration of each operation with the TCM technique, the influence of operation with the TCM technique on income, work burden, the promotion of professional title, and patient healthcare cost, as well as effectiveness of the TCM technique were associated with primary health workers' preferences for the use of appropriate TCM techniques (P<0.05). The latent class model revealed that the opt-out option coefficient for those holding a wait-and-see attitude toward the use of TCM techniques (16.2%) was -3.660 (P<0.001), while that for those supporting the use of TCM techniques (83.8%) was 2.189 (P<0.001). Moreover, those holding a wait-and-see attitude toward the use of techniques exhibited a stronger preference for appropriate TCM techniques that have been proven to be more efficacious (β=1.275), and those supporting the use of TCM techniques showed no significant preference for those with unchangeable effectiveness (β=0.054) .
Primary health workers prefer to use appropriate TCM techniques that can increase their income without workload increase, facilitate their professional title promotion, retain or reduce patient costs, and are covered by health insurance and have good efficacy. To effectively promote primary health workers' enthusiasm in the use of appropriate TCM techniques, it is suggested to add these techniques to the medical insurance reimbursement list, and make a connection between the use of these techniques and title promotion. In addition, different incentive strategies should be adopted for different types of primary health workers.
China has made some achievements in the construction of hierarchical medical system, but the development of its primary healthcare settings is still relatively slow.
To analyze the changes in patient visits and associated determinants in primary healthcare settings in Guangdong during 2013 to 2020, providing a basis for deepening the construction of hierarchical medical system.
In December 2021, this study extracted patient visits in primary healthcare institutions of Guangdong from Guangdong Health Statistics Yearbook (2013—2015), Guangdong Health and Family Planning Statistical Yearbook (2016—2017), and Guangdong's Hygiene and Health Statistical Yearbook (2018—2020) as the reference sequence, and extracted the population data and per capita disposable income from Guangdong Statistical Yearbook 2021, and the financial subsidy for primary healthcare institutions and the number of medical insurance participants from China Health and Family Planning Statistical Yearbook (2015—2017) and China's Hygiene and Health Statistical Yearbook (2018—2021) as the comparative sequence. Grey relational analysis was used to evaluate the strength of correlation between the number of patient visits and its potential associated determinants involving demographic and socioeconomic status, health resource allocation and medical insurance participation.
The number of hospital visits in Guangdong increased from 334.592 million in 2013 to 401.317 million in 2019, with an average annual growth of 3.08%. The number of patient visits in primary healthcare settings in the province reached 437.317 million in 2019, and the average annual growth in these settings was 2.10% during 2013 to 2019. In 2020, the number of patient visits in hospitals and in primary healthcare settings both decreased significantly because of the COVID-19 pandemic. The number of patients visits in primary healthcare settings accounted for 50.7% of all patients visits in medical institutions in 2013, which declined to 48.1% in 2020. Grey relational analysis showed that both the number of residents (r=0.913) and the number of people aged over 65 years old (r=0.913) had the strongest correlation with the number of patient visits in primary healthcare settings, followed by the number of urban-rural resident basic medical insurance participants (r=0.899), the number of beds in primary healthcare settings (r=0.893), the number of primary healthcare settings (r=0.886) and the number of urban employee basic medical insurance participants (r=0.872) .
At present, many patients still choose to hospitals for medical services, which calls for actions to strengthen the first contact in primary care system. It is suggested to meet the needs of residents for nearby medical treatment by enriching the connotation of primary care services, widening the gap of healthcare expenses reimbursed by medical insurance among medical institutions and improving the service capacity of primary healthcare settings under the background of population aging.
As the prevalence of hypertension in China's rural areas is very high, hypertension management in these areas is particularly important.
To summarize the characteristics and weaknesses of hypertension management in Shandong's rural areas using the Innovative Care for Chronic Conditions Framework (ICCC) proposed by the WHO, and to put forward targeted recommendations.
According to the socio-economic level and geographical distribution of hypertension prevalence, three county-level centers for disease control and prevention, 9 town health centers and 36 village clinics were selected from A county of Heze, B district of Jinan and C city of Weihai in Shandong Province, from which 84 cases (including individuals responsible for hypertension management programs, medical workers and hypertensive patients) were selected from June to July 2021 using a purposive sampling method to attend a face-to-face semi-structured interview for understanding the status of hypertension management in Shandong's rural areas. NVivo 12 and Qualitative Data Analysis Model proposed by MILES and HUBERMAN, were used to encode and analyse the interview results using the macro-, meso- and micro-level components of the ICCC.
A total of 13 themes and 51 subthemes were derived from the analysis at three levels. At the macro level, the implementation of hypertension management in Shandong's rural areas was generally in a positive policy environment, such as implementing national policies regarding chronic disease management and publicizing chronic disease management, but the policy framework was not complete, the integration within the departments in the health system was poor, and shortages of professional hypertension managers and sufficient financial support were serious. At the meso level, various medical institutions strived to promote the continuity of medical services, but the organization and deployment of family doctor teams and the promotion and use of information systems still needed to be further strengthened. At the micro level, the cooperation between patients and their families and the family doctor team needed to be improved, and the involvement of patients and their families in hypertension management should be enhanced as well.
The implementation of hypertension management in Shandong's rural areas is good generally, but the following efforts should be made for improvements: vigorously strengthening the leadership and supervision role of the government, formulating and integrating relevant policies, and promoting the integration of relevant departments; increasing financial support, and addressing the relatively shortage of health human resources and improving the weakness of informatization construction in rural areas to promote the delivery of high-quality medical services; attaching importance to the interaction between patients and families, health service team and community partners to promote patients' self-management.
