Elsevier

The Lancet

Volume 390, Issue 10112, 9–15 December 2017, Pages 2584-2594
The Lancet

Review
The primary health-care system in China

https://doi.org/10.1016/S0140-6736(17)33109-4Get rights and content

Summary

China has made remarkable progress in strengthening its primary health-care system. Nevertheless, the system still faces challenges in structural characteristics, incentives and policies, and quality of care, all of which diminish its preparedness to care for a fifth of the world's population, which is ageing and which has a growing prevalence of chronic non-communicable disease. These challenges include inadequate education and qualifications of its workforce, ageing and turnover of village doctors, fragmented health information technology systems, a paucity of digital data on everyday clinical practice, financial subsidies and incentives that do not encourage cost savings and good performance, insurance policies that hamper the efficiency of care delivery, an insufficient quality measurement and improvement system, and poor performance in the control of risk factors (such as hypertension and diabetes). As China deepens its health-care reform, it has the opportunity to build an integrated, cooperative primary health-care system, generating knowledge from practice that can support improvements, and bolstered by evidence-based performance indicators and incentives.

Introduction

The primary health-care system in China, which provides basic clinical care and public health services to a fifth of the world's population, has a notable history. Since its establishment in the early 1950s, it contributed substantially to a reduction in the burden of communicable, maternal, and neonatal diseases through the 1960s and 1970s,1, 2 and helped advance the global primary health-care movement enshrined in the Declaration of Alma-Ata in 1978.3 In subsequent decades, the system faced substantial challenges after market-based reforms in the health-care sector,4, 5 including inadequate government funding6 and weakening of the support of public health-care providers.7 These policy changes led to unintended consequences such as surging costs,8 diminished access to care,8 widening inequities,9 and an erosion of the health-care workforce.10, 11

As part of China's new health-care reform, initiated in 2009,12 the government increased its subsidies to primary health-care institutions from ¥19 billion (US$2·8 billion) in 2008 to ¥140 billion ($20·3 billion) in 2015.1, 13 Additionally, the government instituted universal health insurance coverage,10 a basic public health service programme,14 and a national essential drug system,15, 16 all of which improved access to and affordability of primary health care.17 Acknowledging the increasing pressure exerted by an ageing population, behavioural changes,18 and rapid urbanisation,19 the government's Healthy China 2030 plan20 envisions the primary health-care system as a means of addressing the emerging dual burden of chronic non-communicable diseases21, 22, 23 and increasing health expenditures.1 Despite the importance of primary health care in China and its recent reforms, there is insufficient knowledge about both the current system and the effect of recent policy changes.

In this Review, we aim to assess the primary health-care system and provide a foundation for policy and practice improvements to ensure efficient delivery of high-quality primary health care, particularly to tackle chronic non-communicable diseases. We sought to assess the state of evidence related to the primary health-care system in China, with specific attention towards identifying the challenges in structural characteristics, incentives and financing policies, and quality of care, according to a framework designed for the assessment of primary health-care systems.24 We employed the following methods: a narrative literature review of both published and grey literature; a quantitative data analysis of results from a recent national survey of primary health-care administrators, providers, and patients; and interviews with national experts to interpret themes that emerged from the literature review and the survey (appendix).

Section snippets

Infrastructure, professionals, and services

According to the Declaration of Alma-Ata,25 a primary health-care system is designed to provide universally accessible essential health care to individuals and families in the community as the first level of contact with the national health system. In China, the primary health-care system provides generalist clinical care and basic public health services.

Primary health-care institutions provided 55% of outpatient care (4·4 billion visits) and 18% of inpatient care (41·7 million hospital

Financing policies and incentives for care providers

Despite increased government subsidies for primary health-care institutions since China's reform in 2009, the income associated with clinical care has sharply declined, which has created challenges to the clinical care delivery in the primary health-care system. Moreover, incentive policies for primary health-care professionals do not reward high-quality clinical care.

Since China's market-oriented health-care reform in the 1980s, primary health-care providers have relied heavily on drug revenue

Quality of care

Generally, the quality of primary health care in China is poorly characterised. However, some evidence points to substantial gaps in the quality of processes and outcomes.

There were few studies on the quality of primary health care with respect to outcome measures. Our national survey revealed substantial gaps in the management of hypertension and diabetes, two conditions that are heavily prioritised in the national basic public health service programme. A community-based screening project of

Challenges and opportunities

Even though China has made remarkable efforts and achievements since 2009, its primary health-care system still needs to be substantially strengthened to manage both the rising burden of chronic non-communicable diseases and increasing health expenditures.105 Despite increasing government financial investments, universal health insurance coverage, basic public health service programme, and the essential drug system,12, 106 current policies and technology systems have marked limitations.33, 107

Search strategy and selection criteria

We searched the PubMed, MEDLINE, and China National Knowledge Infrastructure databases (CNKI) on July 28, 2016, to identify relevant studies on seven domains of primary health care in China—structure, human resources, electronic health record system, finance, insurance, medications, and quality of care. In PubMed and MEDLINE, we used MeSH and free-text terms in conjunction to increase sensitivity to potentially appropriate literature published, in English or Chinese, between 1966 and 2016. MeSH

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