Effects of Vertical Integration Reform on Primary Healthcare Institutions in China: Evidence From a Longitudinal Study

How to strengthen primary health care? An exploratory study on the policy of vertical integration of high-quality medical resources based on symbiosis theory

Background

The Vertical Integration of High-Quality Medical Resources (VI-HQMR) is a strategy of medical resource reallocation. It is the key to strengthen primary health care (PHC) and build an integrated delivery system (IDS). It contributes to the Sustainable Development Goals (SDGs) of universal health coverage (UHC) set out by the World Health Organization (WHO). In order to VI-HQMR, countries around the world have carried out many beneficial explorations. However, our understanding of the importance of clarifying the internal logical from policy perspective in the VI-HQMR is limited. This study aims to develop a theoretical model from the symbiotic perspective to improve the strategy of VI-HQMR.

Methods

Policies related to the VI-HQMR were retrieved for exploratory research. The texts and entries were coded according to the four elements of symbiosis theory, the first-level categories and their variables were mined, and the occurrence frequency was used as the main indicator for thematic clustering.

Results

A total of 609 policies were retrieved, among which 1,072 entries mentioned VI-HQMR. Results showed that the VI-HQMR included 482 symbiotic units, 549 symbiotic models, 383 symbiotic environments and 96 symbiotic interfaces. Secondary and above public hospitals and PHC institutions are the most important symbiotic units. Medical alliances are the most important symbiotic model. The symbiotic environment includes policy, technology and economics. The vertical integration of human resources is the main symbiotic interface.

Conclusion

The VI-HQMR is still in the initial exploration stage. The symbiotic model is changing from parasitism to the commensalism. To achieve the optimal mutualism model, we need to work hard from the symbiotic environment. Health administrative department should coordinate with other relevant departments to introduce special policies to support the VI-HQMR. Through opening the way for promotion, financial incentive, and informationization assistance, improve the enthusiasm of urban hospitals.

Impact of China's primary healthcare reforms on utilisation, payments and self-reported health: a quasi-experimental analysis of a middle-aged and older cohort 2011-2018

Background

Comprehensive health reforms aimed at strengthening primary healthcare (PHC) are infrequently adopted and often poorly evaluated in low-income and middle-income countries. China launched a system-wide PHC reform with a staggered roll-out between 2014 and 2018 with multiple components: (1) gatekeeping via tiered reimbursement, (2) a family physician scheme and (3) a two-way referral system between PHC facilities and hospitals. This study examines the reform impacts on health service utilisation, out-of-pocket expenditures, health outcomes and health inequalities.

Methods

The staggered roll-out of the reforms in 125 cities across China was identified using web-scraping. Using longitudinal data (2011-2018) from the China Health and Retirement Longitudinal Study (a cohort aged ≥45), this study adopted a difference-in-differences method to assess the reform's impacts on: (1) visits to PHC facilities, (2) hospitalisation, (3) out-of-pocket expenditures (OOPEs) and (4) self-reported health. Subgroup analyses were conducted by rural/urban populations and wealth quartiles.

Results

The reform had small and short-lived impacts-a 7.8% increase in the probability of visiting PHC facilities (95% CI 0.3 to 15.2), a 10.2% increase in reporting good health (95% CI 0.6 to 19.8) and an 873.9 Chinese Yuan (US$129.1) increase in average annual OOPEs (95% CI 57.9 to 1689.9) in the first year of reform implementation. There was no impact on hospitalisation. Increases in PHC utilisation were only found in rural and lower-income populations.

Conclusions

China's PHC reforms had some modest, temporary impacts on increasing primary care utilisation and self-reported health. However, further interventions are needed to transition away from the hospital-centric health system and to increase financial protection and health equity in China.

The role of construction of healthcare consortium on the allocation of human resources for primary care resources and its equity in China: A quantitative study

OBJECTIVES

This study aims to measure the effect of Construction of Healthcare Consortium (CHC) on the allocation and equity of human resources (HR) for primary health care (PHC) in China, at the same time, it provides some data to support the government's policies improvement in the next stage.

METHODS

Changes in the equity of allocation of HR for PHC by population are demonstrated through a three-stage approach to inequality analysis that includes the Gini coefficient (G), the Theil index (T), the Concentration index (CI) and Concentration curves. Trends in resource allocation from 2021 to 2030 were projected using the GM (1, 1) model.

RESULTS

The average rate of growth in volume of HR for PHC accelerates following the release of CHC in the 2016. Whilst some regions have seen their G and T rise between 2012 and 2016, their levels of inequality of allocation for resource shave gradually declined in the years following 2016, but there are exceptions, with the regions of northeast and northwest seeing the opposite. Eastern and northern region accounted for a larger contribution to intra-regional inequality. Concentration index and concentration curves indicate HR for PHC is related to economic income levels. GM (1, 1) projects a growing trend in allocation of resources from 2021 to 2030, but different regions differ in the average rate of growth of resources.

CONCLUSIONS

The inequality of HR for PHC in China is low, however, the inequality between regions has not been eliminated. We still need to take a long-term view to monitor the impact of CHC on the allocation of HR for PHC and its equity in China.

Health resource allocation within the close-knit medical consortium after the Luohu healthcare reform in China: efficiency, productivity, and influencing factors

Objective

This study aims to assess the efficiency and productivity of the Luohu Hospital Group after the reform and to identify factors influencing the efficiency to support the future development of medical consortia.

Methods

Data on health resources from Shenzhen and the Luohu Hospital Group for the years 2015 to 2021 were analyzed using the super-efficiency slack-based measure data envelopment analysis (SE-SBM-DEA) model, Malmquist productivity index (MPI), and Tobit regression to evaluate changes in efficiency and productivity and to identify determinants of efficiency post-reform.

Results

After the reform, the efficiency of health resource allocation within the Luohu Hospital Group improved by 33.87%. Community health centers (CHCs) within the group had an average efficiency score of 1.046. Moreover, the Luohu Hospital Group's average total factor productivity change (TFPCH) increased by 2.5%, primarily due to gains in technical efficiency change (EFFCH), which offset declines in technical progress change (TECHCH). The efficiency scores of CHCs were notably affected by the ratio of general practitioners (GPs) to health technicians and the availability of home hospital beds.

Conclusion

The reform in the Luohu healthcare system has shown preliminary success, but continuous monitoring is necessary. Future strategies should focus on strengthening technological innovation, training GPs, and implementing the home hospital bed policy. These efforts will optimize the efficiency of health resource allocation and support the integration and development of resources within the medical consortium.

Does vertical integration increase the costs for primary care inpatients? Evidence from a national pilot programme in China

OBJECTIVE

To assess the impact of vertical integration (VI) within County-Level Integrated Health Organisations (CIHOs) on the costs of primary care inpatients.

METHODS

This study assessed Xishui, a national pilot county for CIHOs, using inpatient claims data. The treatment group comprised 10,118 inpatients from 5 vertically integrated township health centres (THCs), while the control group consisted of 21,165 inpatients from 19 non-vertically integrated THCs. The periods from July 2020 to December 2021 and January 2022 to December 2022 were defined as pre- and post-policy intervention, respectively. The primary outcome variables were total health expenditures (THS), out-of-pocket (OOP) expenditures, and the proportion of OOP expenditures. Propensity score matching was employed to align inpatient demographics and disease characteristics between the groups, followed by a difference-in-differences analysis to evaluate the outcomes.

FINDINGS

VI significantly increased THS (β = 0.1337, p < 0.01) and OOP expenditures per case (β = 0.1661, p < 0.001), but the increase in the proportion of OOP expenditures per case was not significant (β = 0.0029, p > 0.05). For the basic medical insurance for urban and rural residents, THS per case (β = 0.1343, p < 0.01) and OOP expenditures (β = 0.1714, p < 0.001) significantly increased. For the basic medical insurance system for employees, THS per case also increased significantly (β = 0.1238, p < 0.01), but the change in OOP expenditure proportion per case was not significant (β = 0.1020, p > 0.05). The THS per case led by Xishui County People's Hospital, the leading county medical sub-centre (CMSC), significantly increased (β = 0.1753, p < 0.01), whereas the increase led by Xishui County Traditional Chinese Medicine Hospital was not significant (β = 0.0742, p > 0.05). Increases in OOP expenditures per case were significant in CMSCs led by the People's Hospital and the Traditional Chinese Medicine Hospital (β = 0.1782, p < 0.01 and β = 0.0757, p < 0.05, respectively).

CONCLUSION

VI significantly increased THS and OOP expenditures for primary care inpatients. However, VI could exacerbate economic disparities in disease burden across different insurance categories.

Uneven primary healthcare supply of rural doctors and medical equipment in remote China: community impact and the moderating effect of policy intervention

BACKGROUND

Unequal access to primary healthcare (PHC) has become a critical issue in global health inequalities, requiring governments to implement policies tailored to communities' needs and abilities. However, the place-based facility dimension of PHCs is oversimplified in current healthcare literature, and formulating the equity-oriented PHC spatial planning remains challenging without understanding the multiple impacts of community socio-spatial dynamics, particularly in remote areas. This study aims to push the boundary of PHC studies one step further by presenting a nuanced and dynamic understanding of the impact of community environments on the uneven primary healthcare supply.

METHODS

Focusing on Shuicheng, a remote rural area in southwestern China, multiple data are included in this village-based study, i.e., the facility-level healthcare statistics data (2016-2019), the statistical yearbooks, WorldPop, and Chinese GDP's spatial distribution data. We evaluate villages' PHC service capacity using the number of doctors and essential equipment per capita, which are the major components of China's PHC delivery. The indicators describing community environments are selected based on extant literature and China's planning paradigms, including town- and village-level factors. Gini coefficients and local spatial autocorrelation analysis are used to present the divergences of PHC capacity, and multilevel regression model and (heterogeneous) difference in difference model are used to examine the driving role of community environments and the dynamics under the policy intervention.

RESULTS

Despite the general improvement, PHC inequalities remain significant in remote rural areas. The village's location, aging, topography, ethnic autonomy, and economic conditions significantly influence village-level PHC capacity, while demographic characteristics and healthcare delivery at the town level are also important. Although it may improve the hardware setting in village clinics (coef. = 0.350), the recent equity-oriented policy attempts may accelerate the loss of rural doctors (coef. = - 0.517). Notably, the associations between PHC and community environments are affected inconsistently by this round of policy intervention. The town healthcare centers with higher inpatient service capacity (coef. = - 0.514) and more licensed doctors (coef. = - 0.587) and nurses (coef. = - 0.344) may indicate more detrimental policy effects that reduced the number of rural doctors, while the centers with more professional equipment (coef. = 0.504) and nurses (coef. = 0.184) are beneficial for the improvement of hardware setting in clinics.

CONCLUSIONS

The findings suggest that the PHC inequalities are increasingly a result of joint social, economic, and institutional forces in recent years, underlining the increased complexity of the PHC resource allocation mechanism. Therefore, we claim the necessity to incorporate a broader understanding of community orientation in PHC delivery, particularly the interdisciplinary knowledge of the spatial lens of community, to support its sustainable development. Our findings also provide timely policy insights for ongoing primary healthcare reform in China.

Explaining the intention and behaviours of interinstitutional collaboration in chronic disease management among health care personnel: a cross-sectional study from Fujian Province, China

BACKGROUND

The increasing number of chronic diseases consumes a large amount of health resources and puts a huge burden on health service system. The integrated management of chronic diseases in Sanming City aims to improve the efficiency and quality of chronic disease management through the collaboration between different levels of medical institutions.

AIM

The aim of the present study was to use the theory of planned behaviour (TPB) to examine the intention and behaviours of interinstitutional collaboration in chronic disease management (ICCDM) among healthcare personnel.

METHODS

A cross-sectional study of 274 health care personnel was conducted in medical institutions in Fujian Province, China, from March 2022 to April 2022. A self-administered questionnaire based on TPB theory was applied to measure the participants' ICCDM behaviours.

RESULTS

The proposed TPB model revealed that attitude was significantly and positively associated with behaviour intention, and behaviour intention and perceived behavioural control were significant predictors of ICCDM behaviour.

CONCLUSION

TPB provides insights into ICCDM behaviour. Due to the fact that attitude, perceived behavioural control, and behavioural intention towards ICCDM behaviour were demonstrated to be significant predictors of ICCDM behaviour, these factors may be a promising focus of ICCDM interventions in the integrated management of chronic diseases in China.

The effects of positive leadership on quality of work and life of family doctors: The moderated role of culture

Background

Quality of work and life (QWL) of family doctors is highly valued in improving access and equity of healthcare; however, the current low level of QWL in many countries and regions needs to be improved urgently.

Methods

This study explored the effect of positive leadership on the QWL of family doctors, as well as the moderating role of culture, via analysis of data from 473 valid questionnaires of family doctors in China as a sample using SEM, hierarchical linear regression, and a simple slope test.

Results

The empirical results show that positive leadership promoted the QWL of family doctors by improving their achievement motivation and coordinating supportive resources. In addition, our hierarchical linear regression analysis found that the interactive items of positive leadership and culture had a positive effect on achievement motivation (β(a)  = 0.192), QWL (β(b)  = 0.215) and supportive resources (β(c)  = 0.195). Meanwhile, culture had a moderated mediating effect on the relationship between positive leadership and QWL via the achievement motivation of family doctors and supportive resources.

Conclusion

These findings suggest that the interaction among multiple factors, including environmental factors, individual physiological features and culture, may influence the impact of positive leadership on the QWL of family doctors. The possible reasons of these findings and theoretical and practical implications are discussed in this study.

How does people-centered integrated care in medical alliance in China promote the continuity of healthcare for internal migrants: The moderating role of respect

Background

Continuity is crucial to the health care of the internal migrant population and urgently needs improvements in China. Chinese government is committed to promoting healthcare continuity by improving the people-centered integrated care (PCIC) model in medical alliances. However, little is known about the driving mechanisms for continuity.

Methods

We created the questionnaire for this study by processes of a literature research, telephone interviews, two rounds of Delphi consultation. Based on the combination of quota sampling and judgment sampling, we collected 765 valid questionnaires from developed region and developing region in Zhejiang Province. Structural equation models were used to examined whether the attributes of PCIC (namely coordination, comprehensiveness, and accessibility of health care) associated with continuity, and explored the moderated mediating role of respect.

Results

The result of SEM indicated that coordination had direct effect on continuity, and also had mediating effect on continuity via comprehensiveness and accessibility. The hierarchical linear regression analysis showed that the interactive items of coordination and respect had a positive effect on the comprehensiveness (β = 0.132), indicating that respect has positive moderating effect on the relationship between coordination and comprehensiveness. The simple slope test indicated that in the developed region, coordination had a significant effect on comprehensiveness for both high respect group(β = 0.678) and low respect group (β = 0.508). The moderated mediation index was statistically significant in developed areas(β = 0.091), indicating that respect had moderated mediating effect on the relationship between coordination and continuity via comprehensiveness of healthcare in the developed region; however, the moderated mediation effect was not significant in the developing region.

Conclusion

Such regional differences of the continuity promoting mechanism deserve the attention of policy-makers. Governments and health authorities should encourage continuity of healthcare for migrants through improving the elements of PCIC-coordination, comprehensiveness and accessibility of healthcare, shaping medical professionalism of indiscriminate respect, and empowering migrants to have more autonomy over selection of services and decisions about their health.

Horizontal Integration and Financing Reform of Rural Primary Care in China: A Model for Low-Resource and Remote Settings

Primary health care (PHC) systems are compromised by under-resourcing and inadequate governance, and fail to provide high-quality health care services in most low- and middle-income countries (LMICs). As a response to solve the problems of underfunding and understaffing, Pengshui County, an impoverished area in rural Chongqing, China, implemented a profound reform of its PHC delivery system in 2009, focusing on horizontal integration and financing mechanisms. This paper aims to present new evidence from the Pengshui model, and to assess the relevant changes over the past 10 years (2009–2018). An inductive approach was adopted, based on analysis of national and local policy documents and administrative data. From 2009 to 2018, the proportion of outpatients who sought first-contact care in rural community or township health centers increased from 29% (522,700 of 1,817,600) in 2009, to 40% (849,900 of 2,147,800) in 2018 (the national average in 2018 was 23%). Our findings suggest that many positive results have been achieved through the reform, and that innovations in financial governance and incentive mechanisms are the main driving forces behind the improvement. Pengshui County’s experience has proven to be a successful experiment, particularly in rural and low-income areas.