Special Issue: Implementation National Essential Public Health Services Programs over the Past Decade
The national basic public health service project has been in operation for more than 10 years since its inception in 2009, and the equalization of basic public health services is one of the most urgent needs of floating population in China.
To evaluate the basic public health services quality of floating population in China, find out existing problems and provide reference for improving the services of floating population.
The quality of basic public health services of the floating population in 31 provinces (direct-controlled municipalities, autonomous regions, excluding Hong Kong, Macao and Taiwan) was comprehensively evaluated by entropy-weight Technique for Order Preference by Similarity to an Ideal Solution (TOPSIS) method using the data of China Migrants Dynamic Survey from 2015 to 2018, and the main impact indicators of the evaluation results were analyzed by multiple regression. Using Rank Sum Ratio method to grade the evaluation results.
The results of entropy-weight TOPSIS method showed that the Ci values of 31 provinces (direct-controlled municipalities, autonomous regions) range from 0.217 to 0.759. The main influencing indicators of the evaluation results were the rate of health records establishment, the rate of type 2 diabetes patients management, the rate of health check-up for children aged 0-6, the rate of health check-up for elderly aged 65 and above, the rate of health handbook establishment for children aged 0-6, the rate of visit within 28 days after delivery, the coverage rate of free pre-pregnancy health check-up for target population, the acceptance rate of health education services, the rate of pregnancy registration within 12 weeks, the basic free contraceptive coverage rate, the rate of basic free contraceptive surgical services, and hospital delivery rate. According to the RSR method, the results of evaluation were divided into 4 grades, the number of provinces (direct-controlled municipalities, autonomous regions) ranked as excellent, good, medium and poor was 2, 15, 12 and 2 respectively. The results of regional comparison showed a pattern of "Central > Western > Northeast > Eastern".
The quality of basic public health services is regionally and interprovincially uneven. We should strengthen the work of health system documentation, hypertension and diabetes management, physical examination of the elderly and children. In particular, the three major urban agglomerations in the eastern region and some mega-cities urgently need to improve the basic public health services quality of Chinese floating population.
Community rehabilitation has much in common with primary health care. While providing primary health care for key groups, primary health care institutions will be of great significance if they can accurately provide rehabilitation services to people in need, reduce their degree of dysfunction, improve their quality of life, and realize the functional positioning of "rehabilitation at the grassroots level". This paper focuses on the coordinated development of community rehabilitation and primary health care, proposes several strategies in service delivery, service cooperation, and service financing, in order to provide references for the expansion of rehabilitation capabilities in primary health care institutions, and hopes to contribute to higher general public health standards and reduced medical expenditures.
The contribution of geriatric health examination services of national essential public health services to the detection of abnormal health conditions in the elderly and the awareness of examination results of the elderly has been rarely reported in the current studies.
To investigate the abnormal detection of several common diseases including abnormal blood pressure, abnormal blood glucose, overweight and obesity, anemia, fatty liver disease, gallstones or cholecystitis in the health examination of the older adults aged 65 years and above.
The older adults aged 65 years and above who visited 20 primary care institutions in 5 cities of 3 provinces in eastern, central and western China were selected as study subjects (excluding those with unclear health examination results in this year) from November to December 2019 by using a multi-stage stratified sampling method, and divided into the general older adults (without hypertension or diabetes), older adults with hypertension, older adults with diabetes. A one-on-one questionnaire survey was conducted on all respondents (The questionnaire included the general demographic characteristics of the respondents and the abnormal detection in the health examination of the elderly) .
Among 3 018 older adults, 2 033 (67.36%) reported abnormalities in the health examination. There were statistically significant differences in the abnormal detection rates of health examination for the older adults with different types of residence, population, and household registration (P<0.05). Among 3 018 older adults, 1 174 (38.90%) self-reported abnormal blood pressure detection, 747 (24.75%) self-reported abnormal blood glucose detection, 719 (23.82%) self-reported dyslipidemia detection, 445 (14.74%) self-reported fatty liver detection, 393 (13.02%) reported overweight and obesity detection, 238 (7.89%) reported gallstones or cholecystitis detection, and 60 (1.99%) reported anemia detection. Abnormal blood pressure was detected in 49.13% of the older adults diagnosed with hypertension during the annual health examination, with the blood pressure control rate of 50.87%. Abnormal blood glucose was detected in 60.48% of the older adults diagnosed with diabetes during health examination with the control rate of blood glucose of 39.52%. Multivariate Logistic regression analysis showed that the detection rate of abnormal blood pressure was 2.57 times〔95%CI (2.01, 3.29) 〕 higher in the older adults with diabetes than in the general older adults; the detection rate of dyslipidemia was 1.64 times〔95%CI (1.29, 2.08) 〕 and 1.42 times〔95%CI (1.10, 1.84) 〕 higher in the older adults with hypertension and diabetes than in the general older adults, respectively; the detection rate of overweight and obesity was 2.79 times〔95%CI (1.94, 4.00) 〕 and 2.64 times〔95%CI (1.80, 3.87) 〕 higher in the older adults with hypertension and diabetes than in the general older adults, respectively; the detection rate of fatty liver was 2.10 times〔95%CI (1.55, 2.85) 〕 higher in the the older adults with hypertension than the general older adults; while the detection rate of anemia was 0.25 times〔95%CI (0.13, 0.47) 〕 and 0.47 times〔95%CI (0.25, 0.86) 〕 higher in the older adults with hypertension and diabetes than in the general older adults; the detection rate of dyslipidemia, gallstones or cholecystitis was 0.76〔95%CI (0.64, 0.90) 〕and 1.32〔95%CI (1.01, 1.73) 〕 times higher in the rural older adults than the urban older adults, respectively (P<0.05) .
The physical examination program for the elderly in the national essential public health services plays an important role in early detection and wareness of health problems.
Launched in 2009, the National Essential Public Health Service Program has been conducted for 13 years. Among which the antihypertensive care ranks first among all types of antihypertensive care in terms of population coverage in China. To promote the sustainable development of the National Essential Public Health Services (NEPHSs) , it is important to understand the feedback of hypertensive population on the antihypertensive care.
To explore hypertension patients' self-rated improvement gained from and satisfaction with the NEPHSs and associated factors, providing a scientific basis for promoting the quality development of the services.
By use of multi-stage stratified sampling, 2 419 hypertensive patients (≥35 years old) were selected from 20 community (township) health centers in 10 districts (counties) of 5 cities in eastern, central and western China from November to December 2019. A questionnaire survey was conducted with them for understanding their general demographic information and management of hypertension.
The prevalence of having self-rated health improvement associated with the NEPHSs in the survey respondents was 86.26% (2 072/2 402) . The prevalence of self-reported satisfaction with healthcare workers' attitudes toward patients, and their care quality, physical examination, health education, TCM treatment, follow-up service, screening for hypertension complications, blood pressure control effect and overall services was 97.15% (2 349/2 418) , 94.09% (2 275/2 418) , 88.16% (2 129/2 415) , 87.81% (2 118/2 412) , 61.36% (1 469/2 394) , 95.04% (2 297/2 417) , 83.67% (2 013/2 406) , 82.34% (1 981/2 406) , and 95.53% (2 310/2 418) , respectively. The prevalence of self-rated improvement gained from the NEPHSs varied significantly by education level, self-rated health, prevalence of blood pressure abnormalities first detected in primary care, and the number of different follow-up services received within the past year (P<0.05) . The prevalence of self-reported satisfaction with overall services differed significantly by education level, prevalence of blood pressure abnormalities first detected in primary care, and the number of different follow-up services received within the past year (P<0.05) .
The prevalence of self-rated improvement gained from and self-reported satisfaction with the NEPHSs in hypertension patients were high on the whole. To promote the sound and sustainable development of these services, priority should be given to the standardization of the provision of NEPHSs and the homogeneity of NEPHSs provided to both urban and rural areas.
As an important measure to deepen the reform of the medical and pharmaceutical health system, the national essential public health services programs has been carried out for more than ten years. Therefore, it is of great significance to evaluate the effect and remaining problems of the programs over the decade of implementation period (2009-2019) and to further promote the country's basic public health services. With reference to Donabedian quality theory, this paper summarized and analyzed the key problems existing in China's basic public health services from the aspects of project objectives, project contents, operation mechanisms, implementation processes and effects, and make relevant suggestions from six aspects, mainly as follows: based on scientific reasoning, dynamically adjusting the programs; suggestion that the national basic public health services should be graded and managed by classification; timely revision of project specifications to improve service quality and efficiency; gradually promoting the effectiveness-oriented evaluation and assessment system; improving operational mechanisms and promoting sustainable development; fully playing the role of county medical community, and enhancing service coordination; establishing a scientific and long-term monitoring mechanism for national essential public health services programs. It provides reference for further improvement and optimization of national essential public health services progjects.
The national essential public health services programs (NEPHSP) is an important project led by the Chinese government to benefit the people, which is a Chinese practice towards universal health coverage. In 2009, the project was rolled out across the country, and its coverage and influence are second to none in the field of public health in China. It is necessary to review the 10-year progress of the project and clarify its effectiveness to maintain its sustainable development.
To systematically sort out and summarize the progress and achievements of the NEPHSP made over the past decade (2009-2019) .
We collected the monitoring data (2009-2016) of basic public health projects in 31 provinces (autonomous regions and municipalities directly under the central government) through correspondence, analyzed the monitoring data of the national basic public health service management platform (2017-2019) and the relevant indicators of the China Health Statistical Yearbook (2010-2020) , and analyzed the coverage of basic public health services in the country over the past ten years from the perspective of providers. From November to December 2019, a ten-year assessment survey of the national essential public health services was carried out in Zhejiang Province, Shanxi Province and Chongqing city to investigate the residents' awareness, utilization, satisfaction and self-assessment benefit rates of NEPHSP from the perspective of the consumers.
During the past decade, the coverage of various service items of basic public health in China has increased significantly: (1) the rate of construction of health file, the rate of construction of electronic health file, and the utilization rate of health file have increased from 48.78%, 35.07% and 22.14% in 2009 to 88.25%, 86.82% and 55.34% in 2019, with an average annual growth rate of 6.41%, 10.92% and 15.62% respectively; (2) A total of 6.311 billion printed health education materials were distributed nationwide, about 337million audio-visual health education materials were broadcasted, and a total of 1.144 billion people attended health education lectures; (3) By 2019, there were about 109 million registered hypertensive patients and about 31 357 100 diabetes patients nationwide. The standardized management rate of hypertensive / diabetes patients has increased by 29.28% and 27.25% respectively in the past decade. The blood pressure / blood glucose control rate in the population managed for hypertension / diabetes has increased by 16.84% and 24.69% respectively in the past decade, with an average annual growth rate of 3.28% and 5.56% respectively. The gap in each indicator among the eastern, central and western regions was gradually narrowing; (4) The rates of early pregnancy enrollment, antenatal examination, postpartum visit and system management increased by 6.06%, 4.60%, 7.79% and 9.40% respectively. The ten-year rates of neonatal visit and health management of 0-6-year-old children increased by 14.09% and 17.82% respectively, with an average annual growth rate of 1.74% and 2.30%. In 2019, the national elderly health management rate was 67.41%, an increase of 26.23% over 2009, with an average annual growth rate of 5.96%. The average annual growth rate of TCM health management services for the elderly and children was 15.00% and 12.97%, respectively; (5) The rate of establishing vaccination certificates and the vaccination rate of all kinds of vaccines among residents were stable at more than 90%; The standardized management rate of patients with severe mental disorders reached 89.17% in 2019, the management rate of pulmonary tuberculosis patients and the regular drug taking rate of pulmonary tuberculosis patients had been stable at more than 95% since 2015; (6) In 2019, the awareness rate of the national essential public health services programs for participating residents in the survey was 85.4%, the service utilization rate was 98.7%, the service satisfaction of the key groups was more than 90%, and the self-assessment service benefit rate was more than 85%; (7) The service capacity of primary medical and health service institutions had been improved, and the number of institutions had shown a continuous upward trend. The number of personnel in primary medical and health institutions, the proportion of doctors and nurses, and the proportion of Bachelor degree or above had all increased year by year.
Over the past decade, as an important part of basic health services in China, the population coverage of basic public health services had increased significantly, the goal of wide service coverage had been basically achieved, the health management level of the focused population had been significantly improved, the effect of health management had been presented, the residents' sense of access to basic public health services had been gradually improved, and the service capacity of basic medical and health institutions had been continuously improved. The comprehensive implementation of basic public health services in China is an important initiative towards the goal of "universal health coverage".
The National Essential Public Health Services Programs (NEPHSP) is a systematic and overall basic public service system arrangement made by the Chinese government at the national level aiming at the main health problems existing in urban and rural residents and targeting at key population key diseases and the whole population. Year of 2019 is the tenth anniversary of the NEPHSP implementation. This article summarized the significance of implementing NEPHSP based on a 10-year evaluation of NEPHSP from four aspects: universal health coverage, Healthy China 2030 strategy, China's deepening health system reform and major institutional innovation. At the same time, several main experiences of successful projects were summarized, including the following five aspects: establishing and improving a strong project organization and management system, steadily increasing strength of financial support, following the principle of gradual implementation of projects, advocating and encouraging local exploration in accordance with local conditions, and adhering to clear reward and punishment performance appraisal. From the historical perspective, this paper summarized the implementation of the great project led by the Chinese government in order to introduce the Chinese way, Chinese practice and Chinese experience of primary health care work in the new era at home and abroad.
Fuzzy Combination of TOPSIS and RSR for Comprehensively Assessing the Quality of National Essential Public Health Services
The national essential public health services have been implemented since 2009 as a key initiative of the new round of China's healthcare reform. With the development of this service program, the allotted special funds and service items are increasing. Due to large number of indicators involved and wide coverage, it is imperative to explore a method that can assess the services scientifically, objectively and comprehensively.
To explore an appropriate method for comprehensively assessing the quality of national essential public health services, providing a basis for improving relevant policies and the quality of such services.
By use of multistage and purposive sampling, 24 community (township) health centers were selected from southern, central and northern Z Province from February to April 2019, and qualities of national essential public health services delivered by them in 2018 were comprehensively assessed using the technique for order of preference by similarity to ideal solution (TOPSIS) , rank-sum ratio (RSR) method, and fuzzy combination of TOPSIS and RSR method, respectively. With reference to the 2018 National Basic Public Health Service Project, 12 evaluation indicators were selected.
According to the TOPSIS-based assessment, the top three community (township) health centers ranked by Ci value were A (0.917 4) , C (0.875 9) and G (0.787 9) , and the bottom three were I (0.414 2) , W (0.413 7) and N (0.407 7) . In accordance with the RSR method-based assessment, the top three community (township) health centers ranked by RSR value were A (0.890 6) , G (0.765 6) , and C (0.711 8) , and the bottom three were V (0.381 9) , W (0.362 8) , and K (0.357 6) . According to the fuzzy set theory, the top three community (township) health centers ranked by W1Ci+W2RSR values were A, C and G, and the bottom three were I, K and W in accordance with the "majority rule", which was basically consistent with the evaluation results of TOPSIS and RSR.
The assessment results by TOPSIS, RSR, and fuzzy combination of these two and associated factors in this study are consistent with those of other studies. Either use of TOPSIS- or RSR-based quality assessment had limitations, but fuzzy combination of the two overcame these limitations, so the combination approach is worthy of promotion as an appropriate method for assessing the quality of essential public health services.
Utilization of National Essential Public Health Services and Its Relationship with Management Effect in Chinese Type 2 Diabetic Patients
The national essential public health services (NEPHS) , which have been implemented since 2009, may be the largest population-based intervention practice for Chinese patients with diabetes currently. It is important to understand the utilization and management effect of such services in diabetic population over this period of more than 10 years of development.
To understand the utilization and management effect of NEPHS as well as their association in Chinese type 2 diabetics.
By use of multi-stage stratified sampling, 1 527 type 2 diabetics (≥35 years old) were selected from 20 community (township) health centers in 10 districts (counties) of 5 cities in eastern, central and western China during November to December 2019. Sociodemographic characteristics, utilization and management effect of NEPHS in these patients were collected by face-to-face surveys with a self-designed questionnaire.
According to the survey, patients' self-reported rates of creating health records, use of health records, undergoing standardized blood glucose tests, and receiving standard follow-ups were 90.34% (1 375/1 522) , 52.80% (725/1 373) , 83.69% (1 262/1 508) , and 90.18% (1 377/1 527) , respectively. Household follow-ups and hospital follow-ups accounted for 29.24% (443/1 515) and 61.06% (925/1 515) of the total last follow-ups, respectively. The analysis of management effect showed that patients' self-reported rates of home-based self-monitoring blood glucose and regular medication in the past 6 months were 53.57% (818/1 527) , and 89.26% (1 363/1 527) , respectively. The rates of patients who were satisfied with glycemic control, and overall medical services assessed in the last follow-up were 65.23% (996/1 527) , and 95.15% (1 453/1 527) , respectively. In those≥65 years old, the prevalence of home-based self-monitoring blood glucose differed significantly by the creation of health records and Chinese medicine services (P<0.05) . The prevalence of regular medication differed significantly by number of follow-ups (P<0.05) . The level of overall satisfaction with services differed significantly by the access to personal medical records at any time, Chinese medicine services, number of home-based self-monitoring blood glucose, and type of follow-up (P<0.05) . In those aged from 35 to 64, the prevalence of home-based self-monitoring blood glucose differed significantly by the creation of health records, access to personal medical records at any time, Chinese medicine services, number of blood glucose testing, and number of follow-ups (P<0.05) . The prevalence of regular medication differed significantly by the type of follow-up (P<0.05) . The satisfaction rate of blood glucose control differed significantly by access to personal medical records at any time (P<0.05) . The overall service satisfaction rate differed significantly by follow-up type and creation of health records (P<0.05) .
NEPHS have influenced community-based management of type 2 diabetic patients, the standard implementation of which has enhanced the management effect and the overall service satisfaction in these patients.