Special Issue: Health Policy Research
Compulsory rural service directed medical student free training program is a medical education policy oriented to the cultivation of high-quality general medical talents for primary care system in rural areas, and is an important initiative to deepen the reform of the pharmaceutical and health system and accelerate the construction of a "healthy China", which is an important foundation for implementing the "poverty removal" and promotion of sustainable development of "poverty alleviation by health". Policy of compulsory rural service directed medical students free training program was designed scientifically and rationally, effectively combining motivating mechanisms with compulsory mechanisms, and is continuously refined in the practice process. In the course of policy implementation, various regions of our country have developed their characteristic implementation strategies accordingly in the links of enrollment, training, employment, and contract performance. The program based on the policy educated a large number of qualified GPs for rural primary care system. The compulsory rural service directed medical students fulfilled the contract well, and the career development trend was positive, which contributed to strengthening the construction of the primary health workforce, enhancing the level of primary health service, and promoting the establishment of a hierarchical diagnosis and treatment system. However, during the implementation of the policy, many challenges have been encountered, such as some students' low learning enthusiasm during the training period, limited capacity of local authorities to implement the policy, the need for improvement of pay incentives for primary GPs and the short service cycle. In this paper, we conducted a systematic analysis of the design concept and execution process of the policy of free training for compulsory rural service directed medical students, and suggested that further expansion of scale of the compulsory rural service directed free training program should be conducted to improve the quality of cultivation, enhance the effective collaboration among multiple parties and the contract fulfillment, which will collectively promote the effective implementation of the policy, thereby providing talent support for the hierarchical diagnosis and treatment system and the "Health China" strategy.
The research on traditional Chinese medicine policies in China's academic circles became increasingly active and the connotations became richer. However, most of the existing research focused on a certain specific field of traditional Chinese medicine policies, lacking all-round comprehensive research. By systematically retrieving China's traditional Chinese medicine-related policies and journal literature from 2011 to 2023 and obtaining the comprehensive statistical system data of traditional Chinese medicine, this article analyzed Chinese medicine policies from the 12th Five-Year Plan to the 14th Five-Year Plan from the perspectives of Chinese medicine, health care, scientific research, education, industry and culture, reviews relevant Chinese medicine policies and measures, sorts out the development status. It found that China had problems such as insufficient basic Chinese medicine service ability, imperfect Chinese medicine health care network, imperfect education model, and weak scientific research strength. It also proposed to strengthen the traditional Chinese medicine medical system, strengthen health care for treating non-sick patients, strengthen the construction of scientific research forces, integrate and innovate the education model, strengthen the supervision of the traditional Chinese medicine industry, and promote the dissemination of traditional Chinese medicine culture and health education.
Rural targeted general practitioners (referred to as "5+3" targeted general practitioners) who have completed 5-year college education and 3-year residency training are an important source of high-level health talents in rural areas. The post attractiveness of primary care general practitioners in China still needs to be improved, and it is necessary to analyze the relevant progress in the use and incentive of "5+3" targeted general practitioners.
To understand the policy and practice of use and incentive of "5+3" targeted general practitioners in targeted rural primary medical care institutions (referred to as "targeted institutions" ) .
August 2024, we reviewed policies and typical practices in various places on use and incentive of "5+3" targeted general practitioners issued by Chinese government since 2010. A series of questionnaire surveys and semi-structured interviews were conducted among "5+3" targeted general practitioners, presidents of targeted institutions and managers ofhealth administrativedepartments in 9 counties (cities) of 8 provinces in the midwest regions through the convergent-parallel mixed methods research.
From the perspective of policy progress, the ues and incentive policy of "5+3" targeted general practitioners in China before 2018 was mainly guidance document. After 2018, relevant policy requirements were more specific, mainly focusing on improving salary levels, hiring and staffing, career development and performance management. Survey data shows: From 2010 to 2015, 9 counties (cities) trained a total of 209 "5+3" targeted general practitioners, with the compliance rate of 90.0% (188/209), of which the compliance rate for the 2010-2012 level was 84.0% (63/75), and the compliance rate for the 2013-2015 level was 93.3% (125/134) ; The pre-work compliance rate was 91.4% (191/209), and the post-work compliance rate was 98.4% (188/191) ; 63 people had completed their service period, and 61.9% (39/63) had renewed their contracts after the service period expired. The annual per capita after-tax wage income of 142 on-the-job "5+3" targeted general practitioners was 54 000 CNY during the training period, and the annual per capita after-tax wage income after entering the targeted institutions was 57 000 CNY. 14.1% (20/142) of them are willing to renew their contracts after the expiration of their service period.
The compliance rate of "5+3" targeted general practitioners continues to increase, and the trend of renewal rate is positive but the willingness to renew is low. There is a gap between the training of "5+3" targeted general practitioners and the actual needs of primary medical care institutions, and the working conditions and career development of "5+3" targeted general practitioners in the targeted institutions are restricted. It is suggested that the government and relevant departments proceed from the actual needs of the grassroots, coordinate and arrange "5+3" targeted general practitioners training, fully implement the incentive policies such as salary and professional title promotion, and formulate the renewal plan after the expiration of service
Barriers and Improving Paths to the Implementation of Contracted Family Doctor Services in China：an Analysis Using Smith's Policy Implementation Process Model
The contracted family doctor services (CFDSs) is a key action selected to be implemented to deepen the reform of the pharmaceutical and healthcare system, enrich primary care services, and achieve the strategic goals of health China. Moreover, the implementation of CFDSs is a main approach to better safeguarding people's health. To effectively promote the development of CFDSs, China has successively launched various relevant supportive policies, and the local governments have been actively exploring practicing approaches. So far, remarkable results have been achieved nationwide, yet there are still many challenges, among which implementation difficulty is a major factor influencing further promotion of CFDSs. We analyzed the implementation process of CFDSs using Smith's policy implementation process model, and identified many barriers to the implementation of CFDSs, such as lack of rule of law, low level of policy executors, insufficient incentives, and impact of policy environment. In view of this, we put forward the following recommendations on exploring innovative policies for sustainable development of CFDSs: designing top-level policy objectives for CFDSs development from perspectives of law and system, improving qualities and professional identity of providers of CFDSs, establishing mutual trust between doctors and patients, and optimizing the policy implementation environment.
Roles of Primary Care in Response to the COVID-19 Pandemic Defined in Policy Documents
The major promise for promoting primary care intuitions to take the initiative to play an active role in containing the COVID-19 pandemic is defining the duties and roles that they should undertake.
To review the policy documents related to COVID-19 issued by China's health administrative departments to make a systematic summary of the responsibilities and duties that should be undertaken by primary care institutions, offering guidance for COVID-19 containment in various regions of China.
In August 2021, we searched the official websites of the National Health Commission of the People's Republic of China (PRC) and its subordinate institutions for policy documents related to COVID-19 using "primary careinstitutions" "prevention and control at the community level" "COVID-19" and "COVID-19 prevention and control" as the main search terms. The policy documents containing "COVID-19 prevention and control" and "primary careinstitutions" were sorted out in chronological order of publication, and their contents were intensively reviewed, organized, summarized and analyzed.
Thirty-four policy documents extracted from the official websites of the National Health Commission of the PRC and its three subordinate institutions (Department of Primary Health, the former Bureau of Medical Administration and the former Bureau of Disease Prevention and Control) were finally enrolled. They were mainly formulated by the Joint Prevention and Control Mechanism of the State Council in Response to the COVID-19, General Office and Department of Primary Health of the National Health Commission of the PRC. According to these policy documents, the major responsibilities of primary care institutions in containing COVID-19 include: early detection and reporting the suspected COVID-19 cases; receiving trainings regarding knowledge related to COVID-19 containment and emergency preparedness drills for coping with the pandemic; strengthening nosocomial COVID-19 infection containment and personal protection against the pandemic; cooperating with the community in fighting the COVID-19 pandemic; implementing health education about COVID-19 containmentusing a scientific approach; health management of priority populations; collecting and submitting nucleic acid samples; COVID vaccination.
Primary care institutions play a vital role in containing COVID-19 in China. The local governments should follow policy guidelines, and take measures according to the local conditions to facilitate the primary care in stitutions to better their performance in response to COVID-19 as frontline responders.
All levels of China gevernment departments have attached importance to community health management services, an important way for disease prevention and resident saveealth improvement, and successively promulgated relevant management policies. However, there is a lack of systematic review and research on the diffusion paths and characteristics of these policies, which are still unclear due to the diversity of promulgating agencies and types of polices.
To explore the process and features of the diffusion of China community health management policies, providing a reference for the formulation and promotion of these kinds of policies.
From June to September 2021, we searched policy documents related to community health management services published from January 1997 to September 2021 in the official websites of all levels of government and health administrative departments, as well as authoritative databases such as PKULAW.com and so on, then quantitatively analyzed the process and features of diffusion of them in terms of four aspects (intensity, breadth, speed, and direction of diffusion) using policy network analysis and keyword analysis by time series.
A total of 1 540 policies related to community health management were retrieved (including 159 central policies and 1 381 local policies) . The development of community health management services in China may be divided into five stages: germination (1997—2004) , formation (2005—2008) , transition (2009—2012) , initial development (2013—2015) and innovation and development (2016—2021) . Policies which were diffused more intensively and widely were promulgated by central agencies of higher administrative levels, and mainly classified as planning, opinions, and laws. The absolute diffusion breadth of the top 10 policies in terms of diffusion intensity exceeded 30, and the absolute diffusion breadth of the top 10 policies in terms of spreading breadth exceeded 20. The diffusion speed of most policies showed a trend of first increasing and then slowing down over time. The diffusion of Chinese medicine health management policies mainly presented parallel diffusion among policy promulgating agencies at the same level, and top-to-bottom diffusion from the central policy promulgating agencies to the local ones.
Through policy diffusion research, we had a comprehensive understanding of the process and characteristics of diffusion of China's community health management policies, and drew a number of conclusions, including the five-stage development of these policies, and the policy diffusion process may be affected by the attributes of the administrative level of the promulgating agencies and types of policies. In addition, the diffusion of these policies could be achieved via multiple paths, with many mechanisms of action such as learning and imitation, with a speed of "first increasing, then slowing down" over time.
In China, schizophrenia patients have a high demand for basic medical care, but irrational healthcare-seeking behaviors among them may cause a waste of health resources. So relevant policies have been promulgated to improve the ensuring of healthcare and reasonably guide schizophrenia patients to seek medical care. The current research on policy factors and healthcare-seeking behaviors has rarely addressed the association between mental health policies and healthcare-seeking behaviors of patients with schizophrenia.
To analyze the influence of policy factors on healthcare-seeking behaviors in schizophrenia patients, to understand the status and outcome of health service utilization in this group under the guidance of basic medical insurance policies and mental health policies, providing empirical evidence for policy improvement.
In November 2019, we obtained a sample of 2 314 schizophrenic individuals with valid key data by matching the personal data in the three-level psychiatric prevention and treatment network system in a district of Chongqing in 2018, with information related to personal health service utilization in the district obtained from the medical insurance information platform of Chongqing Human Resources and Social Security Bureau. Multivariate Logistic regression analysis was conducted with healthcare-seeking behaviors and the medical institution chosen for treatment as explained variables, participation in basic medical insurance (including basic medical insurance for rural and urban non-working residents or basic medical insurance for urban employees, and reimbursement for medical cost due to special outpatient diseases) and mental health policy coverage (involving community rehabilitation services, guardianship subsidy, subsidy from the local disability federation, subsidy from the 686 program, and free second-generation antipsychotics, and the mental disability certificate) as key explanatory variables, and patients' demographic characteristics as control variables.
Of the participants, 1 915 (82.76%) had medical visits, including 1 482 seeking outpatient treatment, and 795 seeking inpatient treatment. Among those seeking outpatient treatment, the prevalence of choosing primary, secondary and tertiary care institutions was 17.01% (252/1 482), 72.87% (1 080/1 482), and 10.12% (150/1 482), respectively. And the prevalence of choosing primary, secondary and tertiary care institutions for inpatient treatment was 4.78% (38/795), 65.16% (518/795), and 30.06% (239/795), respectively. Logistic regression analysis showed that the type of basic medical insurance, reimbursement for medical cost due to special outpatient diseases, receiving community rehabilitation services, enrolment in the 686 program and involvement in the free second-generation antipsychotics program were factors associated with healthcare-seeking behaviors (P<0.05). The type of basic medical insurance, reimbursement for medical cost due to special outpatient diseases, receiving community rehabilitation services, enrolment in the free second-generation antipsychotics program, and the level of mental disability were factors associated with choosing outpatient settings for treatment (P<0.05). The type of basic medical insurance and the level of mental disability were associated with choosing inpatient settings for treatment (P<0.05) .
Policy factors played a positive role in guiding schizophrenia patients to seek medical treatment, but some problems were also revealed, such as low patient participation and insufficient coverage pathways. In view of this, efforts should be made as soon as possible to optimize mental health policies and the social support and assistance system, increase patient participation of relevant programs via strengthening the publicity of relevant policies, actively guide home-based rehabilitation activities, further promote community-based delivery of mental health services, and continuously improve the mental health security system.
China is increasingly emphasizing the prevention and control of chronic diseases, with the number and variety of related policies showing a growing trend. With the intensification of population aging, multimorbidity has become a critical challenge in the field of public health, necessitating the urgent optimization of relevant policies.
This study aims to reveal the characteristics and priority areas of chronic disease policies and identify potential directions for policy improvement.
Based on a three-dimensional framework of policy tools, policy evolution, and policy actors, content analysis was conducted using NVivo 20.0 software to encode and classify relevant policy documents issued from January 2009 to January 2024. Social network analysis was applied using Ucinet 6.0 software to examine the collaboration network among policy actors, and statistical analyses were performed using Excel 2021.
Analysis of the 68 included policy documents identified a total of 279 references to policy tool usage, comprising 135 instances of supply-side tools, 27 instances of demand-side tools, and 117 instances of environmental tools. The General Office of the State Council accounted for the highest proportion of policy tool references (35.48%, 99/279), while the National People's Congress (NPC) and its Standing Committee accounted for the lowest (2.87%, 8/279). In the social network analysis, the collaboration network density among policy actors was 0.631, with the National Health Commission exhibiting the highest centrality. Further analysis of the 68 policies revealed an increasing trend in both the number and variety of policy tools as policies evolved, though supply-side tools remained predominant (35 policies). The NPC and its Standing Committee were involved in relatively few policies (3 policies). Moreover, only 10 out of the 68 policies addressed multimorbidity.
The results indicate structural imbalances in the use of policy tools and insufficient collaboration among policy actors. The number of policies addressing multimorbidity is limited, and specialized policies in this area are lacking. To address the challenges of chronic disease prevention and control, it is recommended to optimize the allocation of policy tools, enhance coordination among policy actors, and promote the development of specialized policies for multimorbidity. Expanding policy coverage and transitioning from a single-disease management model to an integrated multimorbidity management approach are essential to comprehensively strengthen the capacity for chronic disease prevention and control.
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.
Urban community health services are key to promoting the high-quality development of community health. However, previous studies have seldom explored the evolutionary logic and development trend of community health service policies. It is difficult to provide a comprehensive answer to the questions of the generation, evolution and trend of community health service policies in China.
To understand the current status, evolutionary logic and trend of community health service policies, in order to provide intellectual reference for promoting the high-quality development of community health services and implementing the hierarchical diagnosis and treatment system.
The Central People's Government website, National Health Commission, relevant official provincial websites, CNKI, China Community Health Association and other platforms were searched from December 2019 to March 2022 for community health service reform related policies published at national level (n=98) from January 1997 to March 2022. The included policies were analyzed with the help of the policy orientation analysis model.
The policy changes in urban community health services of China have gone through four stages since 1997, including initial exploration centered on the transformation and frame construction (from 1997 to 2002), normative construction focusing on the bottom of the public health network (from 2003 to 2008), prosperous development focusing on the mechanism reform (from 2009 to 2016), and deepening reform centered on quality improvement and empowerment (from 2017 to 2022). The changes in community health service policies in China follows the following evolutionary logic, including the dynamic mechanism from marketization to professionalization and social community linkage governance, target orientation from scale expansion to internal quality improvement, policy discourse changing from predominantly economics-based discourse to multiple tools coordination.
Community health service policies should promote the innovation of the dual collaborative governance framework and mechanism, strengthen the coordination among professional systems and their effective synergistic linkage with the social community governance systems; promote community value-based health care and trust-based health care with health as the core, establish and improve evaluation standards for the capacity and quality of specialized primary care; promote the diversified application and matching of policy tools to adapt to the diversified needs of community health and wellness interests.
Population aging is getting worse in our country. Family doctor contract service plays an important role in boosting the construction of hierarchical diagnosis and treatment system and establishing a reasonable and orderly medical order. Current research about family doctor contract service policy mainly focus on qualitative evaluation, and there are few researchers use tools to quantitatively evaluate each individual representative policy.
This study aims to quantitatively evaluate the pros and cons of six Chinese central government policies about family doctor contract service, thus, proposing strategies and measures to promote the high-quality development of our country's family doctor contract service, and helping the construction of healthy China.
We searched Peking University's PKULAW.com and websites of some relevant ministries of the State Council of China from January 1, 2015 to April 30, 2022. The key word was "family doctor". The software ROSTCM 6.0 was used for text mining. Based on the results, this study selected central government policies about family doctor contract services, then used the PMC index model to quantitatively evaluate these policies.
This study included thirty-two policies based on inclusion and exclusion criteria. The top five high-frequency keywords in the field of family doctor services are "contract service" (n=274) , "health" (n=272) , "medical" (n=264) , "family doctor" (n=225) , and "contract" (n=180) . They were marked as P1-P6, respectively. In terms of methods and other aspects, the scores of each dimension are relatively high. The results of quantitative evaluation showed that the ranking of policies is P1>P3>P2>P6>P4>P5. Three policies were rated as excellent, the other three were rated as acceptable. The scores were relatively high in the policy content, policy nature, policy evaluation, policy field and policy role.
Our country's family doctor contract service policy had a relatively broad content and is relatively mature. It is suggested to pay attention to the combination of long-term, medium-term and short-term validity of the policies, improve incentive approaches from multiple perspectives, enhance the sense of professional honor of family doctors, and use a variety of policy tools and policy action.
As an important tool to promote hierarchical diagnosis and treatment, contracted family doctor services has experienced from pilot to full implementation, and is the core work of the current primary healthcare service system. According to the policy development and social demand, this paper focuses on the high-quality development of contracted family doctor services, interprets the policy value of high-quality contracted family doctor services in promoting hierarchical diagnosis and treatment, promoting medical and preventive integration as well as promoting the professionalisation of primary healthcare services, and elaborates the role path of high-quality contracted family doctor services in service mode, service content, service model and service guarantee. Finally, it points out that there are three major challenges in the development of high-quality contracted family doctor services, namely, the lack of timely policy support, the shortage of talents at the grassroots level, and the lack of a strong sense of accessibility for the residents.
Since August 2022, Shengzhou City of Zhejiang Province has been carrying out the reform of outpatient payment mode in medical insurance, gradually carrying out the reform of capitation by implementing the total budget, updating the calculation standard of capitation fee, improving the incentive and constraint mechanism and other measures, so as to encourage primary health care institutions to provide appropriate basic medical services, reduce primary medical expenses, and promote the sustainable development of medical insurance fund.
To analyze the influence mechanism of capitation for outpatient services in basic medical insurance on medical expenses in Shengzhou City, Zhejiang Province, and to provide reference for improving the relevant payment system.
Using "capitation" and "medical costs" as both English and Chinese search terms, databases such as CNKI, Wanfang, PubMed and Web of Science were searched for relevant literature on capitation from 2000-01-01 to 2022-07-31, as well as the policy documents, government reports and news reports related to the implementation of capitation from April to July 2022. Personal interviews were conducted with representatives of capitation payment policy makers and implementers in Shengzhou City from September to December 2022 (n=13) . A qualitative analysis of capitation reform policy on medical expenses under the total outpatient budget in Shengzhou City, Zhejiang Province was performed by using system dynamics approach.
The policies of the current round of medical insurance payment reform in Shengzhou were plotted as a cause graph with five feedback loops obtained, showing that the implementation of the total capitation budget policy can motivate primary health care institutions to provide standardized medical services for residents, promote an increase in the contracting rate in primary care, thus controling medical expenses; a scientific capitation fee standard can motivate primary health care institutions to autonomously control and reduce costs; increasing the reimbursement ratio of medical insurance can effectively reduce the medical burden of patients; improving the performance appraisal system is conducive to the continuous improvement of service capabilities of primary health care institutions; strengthening the construction of information sharing mechanisms can achieve data sharing and exchange, and comprehensively improve the health of residents.
The implementation of capitation reform in conjunction with multiple policy measures can improve the contracting and consultation rates in primary care institutions, broaden the sources of medical insurance fund, ensure the sustainability of medical insurance fund, improve the medical service and capabilities of primary care institutions, improve the health status of residents, and significantly improve the prevention and treatment effect of chronic diseases.
Falls among older adults will cause a heavy burden on society and families. The development of effective falls prevention intervention policies for community-dwelling older adults is an important initiative to address this global public health problem.
To analyze and compare the content composition, key initiatives and implementation strategies of current falls prevention intervention policies for community-dwelling older adults in different countries from the perspective of policy tools.
Six countries in Asia, North America, and Europe, including Japan, Singapore, Thailand, the United States, Germany, and Russia, were selected as sample countries according to the degree of population aging and economic income level. Refer to the websites of relevant government departments such as the Ministry of Health, the Center for Disease Control and Prevention and directly affiliated institutions, as well as websites of nongovernmental organizations, such as Prevention of Falls Network Europe, National Council On Aging, U.S., Association of Fall Prevention, Japan, and National Association of Statutory Health Insurance Funds, Germany, the national policy documents of prevention interventions for community-dwelling older adults from January 2010 to June 2022 were searched by using "older adults" "fall/drop/accidental injuries" "prevention" as keywords. The text analysis was performed from the dimensions of policy tools such as demand-side type, supply-side type and environmental-side type, and injury prevention strategies such as education prevention strategies and evaluation strategies.
Among the 24 policy documents, there were 212 coded targets in the dimension of policy tools, with environmental-side type, supply-side type and demand-side type policy tools accounting for 45.3% (96/212), 40.6% (86/212) and 14.1% (30/212), respectively. Among high-income countries, the public service tools under supply-side type policy tools were mostly applied in the United States and Germany, accounting for 40.5% (17/42) and 13.8% (8/58) ; the infrastructure construction tools under supply-side type policy tools were focused in Singapore〔24.1% (7/29) 〕. Among low and middle income countries, the environmental-side type policy tools were mostly applied in Russia and Thailand, accounting for 51.3% (20/39) and 55.6% (10/18), respectively. Public service was mostly applied among the supply-side type policy tools, accounting for 17.5% (37/212) ; technical standard was mostly applied among the environmental-side type policy tools, accounting for 10.8% (23/212) ; medicare payment was mostly applied among the demand-side type policy tools, accounting for 4.7% (10/212). In addition, there were 105 coded targets in the dimension of injury prevention strategies, with the education prevention strategies accounting for the highest proportion of 31.4% (33/105), the engineering strategy accounting for the lowest proportion of 5.7% (6/105). High-income countries are at the stage of multi-sectoral collaborative policy implementation, low and middle income countries are at the stage of policy implementation by the Ministry of Health stage.
Six countries focus on public service and infrastructure development under supply-side type policy tools; the application of demand-side type policy tools can be summarized as intervention services managed by medical insurance, intervention projects supported by financial funds, service purchases attracted by price subsidies, planning, organization, advocacy, and standard setting of environmental-side type policy tools. In combination with the priorities and specific measures of the six countries, it is suggested to learn from advanced experience in improving public services, strengthening evidence-based projects, standardizing technical standards, supporting financial incentives, expanding medical insurance programs, and providing price subsidies, thus further optimizing falls prevention intervention policies for community-dwelling older adults.
Responding to the increasing demand for privacy encryption in image-based medical big data, it is of great importance of proposing an innovative framework of coded-based privacy-preserving segmentation technology, and exploring the implementation pathways to facilitate the practical application of this technology from a collaborative perspective of technology and policy legislation.
To develop a privacy protection technology framework tailored for image-based medical big data, and propose policy and legislative coordination strategies to advance the technology's adoption, in order to enhance the healthcare informatization service system by combining technological innovation with policy support.
Construct the innovative framework for privacy preserving segmentation technology in medical image big data by literature review, theoretical analysis, technology framework development, experimental validation, and policy analysis, and then propose the policy and legislative coordination strategies.
We successfully construct the innovative framework for privacy preserving segmentation technology in medical image big data and though the effectiveness verification, and propose specific policy and legislative recommendations addressing the inadequacies of existing laws and regulations in areas such as cloud data processing, liability attribution, technical standards, and special data protection.
Coded-based innovative framework for privacy preserving segmentation technology in medical image big data can enable effective sharing and utilization of image-based medical data by safeguarding patient's privacy, significantly enhance the data security and privacy protection level, and the proposing of corresponding policy and legislative coordination strategies offers novel insights and approaches to secure governance in this domain.
Policies Implemented in Beijing for Guaranteeing Healthcare for Community-dwelling Patients with Noncommunicable Diseases during the COVID-19 Pandemic
The COVID-19 pandemic brings about influence and challenge for ensuring healthcare services for non-communicable diseases. To guarantee the healthcare services for community-living patients with non-communicable diseases and to meet their healthcare needs, the Beijing municipal government issued a series of policies and relevant supporting measures, including five parts: promoting the implementation of the extended prescription policy, providing Internet-based medical services, further implementing the hierarchical medical system, giving full play to the role of family doctors, and carrying out the service of doorstep delivery of medicines. We reviewed and summarized policies and corresponding measures implemented in Beijing for guaranteeing healthcare for community-dwelling non-communicable disease patients during COVID-19 early response period and ongoing containment period. By evaluating the implementation effect of the policies and comparing with those at home and abroad, it is found that the community chronic disease management under the continuous epidemic situation can be further optimized in the future from the aspects of strengthening the training of grass-roots medical personnel, paying attention to the monitoring of chronic diseases and their risk factors, accurate health management, continuing to implement the hierarchical diagnosis and treatment system, and exploring the whole cycle health management of chronic diseases.
In January 2022, Longhua District, Shenzhen piloted a digitally enabled generalist and specialist collaborative care model to deliver consistent, continues services for patients with chronic conditions managed in community health centers. This system-level initiative integrated hospital-based specialists and community-based general practitioners through a vertically aligned care model supported by a shared digital platform.
To evaluate the effect of this digitally enabled generalist-specialist collaborative care model on hypertension management capacity at community health centers.
We employed a difference-in-difference approach to examine changes in center level outcomes before and after the model was implemented during 2021-2024. The treatment group included 84 health centers in Longhua District, and the comparison group included 448 health centers in the rest of districts that were not influenced by the policy. Health centers in treatment group used the collaborative care model to delivery follow-up services, whereas health centers in comparison groups continued to provide routine services in accordance to the National Basic Public Health Services Program Standards (Third Edition) . Multivariate linear regression with district and time fixed effects was constructed, controlling for health center characteristics and adjusting for inverse probability of treatment weights, with standard errors clustered at the center level. Robustness checks were conducted to evaluate the reliability and stability of the model.
After the implementation of the digitally enabled collaborative care model, compared to centers in comparison groups, on average, quarterly standardized hypertension management rate and hypertension control rate in the treatment group increased by 4.3-percentage-point (DID=0.043, SE=0.011, P<0.001) and 11.5-percentage-point increase (DID=0.115, SE=0.012, P<0.001) per center, respectively. On average, the quarterly number of upward referrals per center decreased by 17.1% (P=0.038) , and the quarterly number of total patient visits per centers increased by 22.1% in treatment group (P=0.003) , as compared to comparison groups.
Our study highlights the significance of the digitally enabled specialist and generalist collaborative care model in enhancing health center capacity in hypertension management, reducing upward referrals, and optimizing resource utilization. Our study underscores the importance of incorporating this initiative into national health strategies, such as the National Basic Public Health Services Program, to strengthen chronic care management services delivery in more areas of China. Future policies and research should focus on scaling up this approach to a broader range of medical conditions and prioritizing investments in health centers by ensuring stable funding streams and optimizing the implementation strategies for digital integration pathway.
Over the fifteen years since the deepening of medical and healthcare system reform in China (hereinafter referred to as deepening healthcare reform in China), a series of policies have been intensively introduced by the central government to promote the development of the general practitioner system. With strong government support and guidance, general practice in China has made positive progress in discipline construction, training and education, and workforce development. The proportion of medical schools with general practice teaching institutions increased from 21.1% in 2010 to 85.7% in 2019, showing an increase of 64.6 percentage points. Meanwhile, the proportion of medical schools offering general practice courses increased from 46.1% to 81.1%, showing an increase of 35.0 percentage points. The number of general practitioners trained through various pathways increased from 109 800 in 2012 to 561 800 in 2023, with an average annual growth rate of 16.00%, far exceeding the growth of licensed (assistant) physicians nationwide (5.64%). The proportion of general practitioners in the total number of physicians increased from 4.20% to 11.75%, showing an increase of 7.55 percentage points. During 2010-2024, the actual enrollment of rural order-oriented medical students reached 89 000, displaying increased number of general practitioners and improved educational qualifications in rural areas of central and western China. General practice beds increased from 307 900 in 2009 to 487 800 in 2023, with an average annual growth rate of 3.34%. General practice outpatient and emergency visits increased from 431 million in 2009 to 848 million in 2023, maintaining approximately 13.00% of the national total outpatient and emergency visits. Among them, the proportion of primary-level general practice outpatient and emergency visits to total primary-level outpatient and emergency visits increased from 26.32% to 33.07%. General practice inpatient admissions increased from 11.275 2 million to 12.247 9 million. The proportion of national total discharges decreased from 8.47% to 4.07%, while the proportion has increased in the past two years by 0.39%. Compared with other secondary clinical disciplines, general practice still has a room for continuous improvement, including weak quantity and quality of general practitioners, limited research capacity, unbalanced distribution of general practitioners at the national level, insufficient numbers of high-quality general practitioners, and inadequate attractiveness of general practitioner positions. Moreover, increased health demands brought by the overlapping effects of population aging and chronic disease prevalence are great challenges to be solved. Based on in-depth analysis, this paper proposed targeted recommendations.
Hypertension is a common chronic non-communicable disease affecting the health of the people in China. As an important gateway for hypertension management and control, the management ability of primary care directly affects the management effect. The current status and common rules of hypertension management in primary care in China need to be further explored.
To understand the current status of hypertension management in primary care in China, summarize the typical experience, and provide suggestions for the optimization of hypertension management in China.
From November to December 2021, semi-structured interviews were conducted with 29 hypertension management stakeholders in five provinces in China. Guided by the World Health Organization's health system, the interviews were analyzed from six dimensions of leadership and governance, service delivery, health workforce, health financing, access to medicines and equipment, and health information system.
For leadership and governance, hypertension management in primary care mainly relies on contracted family doctor service, and requires the collaborative management of medical institutions and public health departments. In terms of service provision, general practice and specialty integration services should be provided to meet the individual medical needs of patients. For health workforce, community general practitioners are the main force of hypertension management in primary care, and their work motivation should be improved by performance appraisal and distribution according to their work. For health financing, hypertensive patients can obtain preferential policy support of medical insurance reimbursement at primary care. For medicine accessibility, basic medical equipment and essential hypertension drugs are available in primary care. For health information system, the regional medical and health information platform can realize health information sharing and service coordination among contracted patients.
Primary health care institutions are responsible for the long-term follow-up and management of hypertension patients. It is necessary to further enhance the capacity of primary health care comprehensive management and primary health service supply, strengthen the capacity building of primary health care personnel, improve the reimbursement and payment system of medical insurance, improve the drug and equipment conditions for hypertension treatment in primary care, and effectively empower hypertension management in primary care through informatization, which can effectively improve hypertension management in primary care.
Children, as a special group, have received public attention. Although a series of policies have been released in recent years to ensure the safety of children's medication, there are still problems such as fewer suitable varieties of drugs and irrational use of medication, which require scientific and reasonable policies on children's medication to promote their development.
To quantitatively evaluate China's pediatric drug policy texts and provide reference for the formulation and improvement of future pediatric drug policies.
Based on the text mining method, 23 pediatric drug policy documents issued at the national level from 2014 to 2023 were processed, the policy modeling consistency (PMC) index model of pediatric drug policy was constructed, and the quantitative evaluation and analysis of China's 23 pediatric drug policies were carried out through 10 primary variables and 41 secondary variables.
The mean value of PMC index of the 23 policies on pediatric drug was 5.65, and the mean value of PMC depression index was 4.35, including 1 excellent-grade policy, 17 good-grade policies and 5 qualified-grade policies, and there were no perfect-grade policies and bad policies. 23 medication policies for children scored high on policy tools and policy receptors and low on publishing organizations and policy timeliness.
China's pediatric drug policy is generally at a good level, and can be further improved in terms of policy timeliness, issuing organization and policy content.
After being completely promoted for less than seven years, China's contracted family doctor service work still faces a number of development problems. The primary obstacle impeding the work of contracted family doctor service is an inadequate guarantee mechanism. There is an urgent need for scientific and reasonable policies on contracted family doctor service to guarantee the effective development of the work.
To quantitatively analyze the textual content of China's contracted family doctor service policies, to explore the focus and shortcomings of the existing policies, and to provide the basis and reference for the development and optimization of the subsequent contracted family doctor service policies.
Policy texts were collected by visiting the official websites of the China government and the National Health Commission of the People's Republic of China on 2023-01-10, and 15 policy texts on contracted family doctor service from 2015—2022 were selected to construct a three-dimensional analytical framework of policy tools-stakeholders-policy strength, to categorize, code, and analyze the policy documents.
Supply-based, demand-based, and environment-based tools accounted for 30.5% (69/226), 19.0% (43/226), and 50.5% (114/226) of the policy tool dimension. Family doctors, contractors, non-contractors, primary medical and health care institutions, hospitals (secondary and above), and the government accounted for 29.2% (123/422), 14.7% (62/422), 9.2% (39/422), 21.3% (90/422), 13.3% (56/422), and 12.3% (52/422) of the stakeholder dimension. The average strength of China's contracted family doctor service policies was 2.2 points. In the cross-dimension of policy tools-stakeholders, the distribution of stakeholders in supply-based and environment-based tools was relatively poor. There were some sub-tools that were absent from the policy tools. In the cross-dimension of policy tools-policy strength, environment-oriented policy instruments were used more often as policy strength increased. In the cross-dimension of stakeholders-policy strength, there were large differences of the policy strength matching scores among various stakeholders. Family doctors had the highest score (311 points) with non-contractors the lowest score (90 points) .
From the perspective of policy tools, policy tools should be allocated rationally, with the weight of use continuously adjusted, the internal structure optimized, and the rationality of the distribution of policy tools among stakeholders improved. From the stakeholder's perspective, all stakeholders should be taken into account, their respective positions need to be clarified, and the demand of the non-contractors should be emphasized. From the perspective of policy strength, the policy supervision and management capacity ought to be strengthened to continuously improve the implementation of the policy of contracted family doctor service.
In order to solve the children's medical dilemmas of poor accessibility and high cost, a hierarchical medical system has been carried out in our country. No systematic research on policy analysis of children's hierarchical medical system has been reported in China at present.
Beijing and Shenzhen are the first pilot cities of the hierarchical medical system, but there are obvious differences in the status of community health services for children. This study aims to explore the impact of policies on community health services for children by analyzing the policies in these two cities.
According to the research framework of policies on community health services developed by an expert group (community first contact care, dual referral, medical alliance, salary compensation mechanism, pediatric professional training, publicity, rural medical accessibility), policy documents about hierarchical medical services for children were searched from the official website of Beijing Municipal Government, Beijing Municipal Health Commission, Shenzhen Municipal Government, and Shenzhen Municipal Health Commission. Compare the number and content of policies that meet the inclusion and exclusion criteria in the two cities and analyze similarities and differences.
Thirty-five policy documents that fit the research framework were selected from 6 953, of which 27 were from Beijing and 8 from Shenzhen. Both cities have policies on medical alliances, wage incentives and pediatric training. Compared with Shenzhen, Beijing has policies on publicity, and rural medical accessibility, but not on community first contact care and dual referral.
It may be of great significance to improve the situation of community health services for children by implementing the community first contact care or increasing the gap in medical insurance payment ratio, completing the indications for dual referral, promoting the medical alliance, salary compensation mechanism and training of pediatric skills policies.
The accessibility and quality of ambulatory care (including outpatient and emergency services in primary care facilities, hospitals and other healthcare facilities) determine the efficiency of overall health care system and population health. Ambulatory care is also the core component of continuing care in an aging society. The concept of ambulatory care sensitive conditions (ACSCs) was firstly introduced by American researchers in 1990s. Since then, hospitalization for ambulatory care sensitive conditions (ACSHs) was widely used to evaluate the accessibility and quality of ambulatory care. In recent years, research on ACSH has gradually attracted the attention of scholars from all over the world, and preliminary research evidence from China indicated that the issue should not be ignored. This paper firstly introduces the origin of the concept of ACSH, then identifies the mixing concepts such as ACSH, avoidable hospitalization and inappropriate hospital admission, systematically summarizes the cutting-edge international identification criteria of ACSH, and finally discusses the policy value of ACSH as an indicator in the context of domestic and international research advances, clarifies the problems that should be noted in the identification of ACSCs in China, proposes strategies to reduce ACSH.
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.
Since the implementation of the "universal two-child" policy, multiparous women has become the main labor and delivery population. Problems such as advanced maternal age, chronic comorbidities, obstetric complications and pregnancy after cesarean section have become increasingly prominent, bringing new challenges to obstetricians.
To analyze the current status of cesarean section in multiparous women under the new childbearing policy based on the revised Robson classification system, in order to provide data support for rational control of cesarean section rate, improvement of obstetric care.
A total of 19 170 women who delivered by cesarean section in the Tenth Affiliated Hospital, Southern Medical University from 2017 to 2020 were included and divided into the primipara group (n=5 630) and multiparous group (n=13 540). Maternal information including age, gravity, parity, previous deliveries, fetal position, pregnancy comorbidities and complications, maternal and fetal outcomes, was collected through the electronic medical records. The general information and maternal and neonatal outcomes of the two groups were compared. The revised Robson classification system was used to classify the parturients according to their obstetric characteristics (parity, fetal position, number of fetuses and gestational weeks of delivery). The distribution of parturients in the revised Robson classification system and the change of the proportion of parturients in each group with year were compared.
The proportion of pregnancy after cesarean section was as high as 81.4% (11 026/13 540). The age, gravity, parity, proportion of age ≥35 years and gestational diabetes mellitus of the multiparous group were higher than the primipara group (P<0.05). Based on the revised Robson classification system, R3 class (singleton cephalic position at ≥37 weeks' gestation with a history of at least 1 cesarean delivery) accounted for the highest proportion (50.4%, 9 668/19 170) in all cesarean section, followed by R1 class (singleton cephalic primiparous labor at≥37 weeks' gestation, spontaneous labor, induced labor, or cesarean section before labor) (20.8%, 3 993/19 170). In multiparous women, R3 class accounted for 71.4% (9 668/13 540). Analysis of the population characteristics of multiparous women found that the proportion of R3 class, which had the highest proportion, decreased from 73.5% to 67.1%, while the proportion of R2 class [transplants with singleton cephalic position at ≥37 weeks' gestation (without history of cesarean section), spontaneous labor, induced labor, or cesarean section before labor], and R8 class [all singleton cephalic positions at <37 weeks' gestation (including history of cesarean section) ] all increased. The 24-h postpartum hemorrhage and the proportion of blood transfusions were higher in the multiparous group than the primipara group, while length of hospital stay after surgery was lower than that in the primipara group (P<0.05). A total of 20 026 newborns were delivered by 19 170 women, including 6 077 primipara women and 13 949 multiparous women; the birth weight and 1-minute Apgar score of neonates in the multiparous group were higher than the primipara group, while the proportions of 1-minute ≤7 and neonatal transfers were lower than those in the primipara group (P<0.05). There was no significant difference in 5-minute Apgar score between the two groups (P>0.05) .
Advanced age and pregnancy after cesarean section are prominent features of multiparous women. Although the proportion of R3 class decreased by year, it is still the main population of cesarean section. In order to reduce cesarean section rate, it is necessary to effectively control the cesarean section of primipara women, and actively promote the vaginal trial of labor for women in R3 class. Meanwhile, the proportion of R2 and R8 in the multiparous women, which put forward new requirements for clinical practice of obstetrics.
