A path dependence analysis of hospital dominance in China (1949-2018): lessons for primary care strengthening

Trends in the mobility of primary healthcare human resources in underdeveloped regions of western China from 2000 to 2021: Evidence from Nanning

OBJECTIVE

This research aimed to identify the fundamental and geographic characteristics of the primary healthcare personnel mobility in Nanning from 2000 to 2021 and clarify the determinants that affect their transition to non-primary healthcare institutions.

METHODS

Through utilizing the Primary Healthcare Personnel Database (PHPD) for 2000-2021, the study conducts descriptive statistical analysis on demographic, economic, and professional aspects of healthcare personnel mobility across healthcare reform phases. Geographic Information Systems (QGIS) were used to map mobility patterns, and R software was employed to calculate spatial autocorrelation (Moran's I). Logistic regression identified factors that influenced the transition to non-primary institutions.

RESULTS

Primary healthcare personnel mobility is divided into four phases: initial (2000-2008), turning point (2009-2011), rapid development (2012-2020), and decline (2021). The rapid development stage saw increased mobility with no spatial clustering in inflow and outflow. From 2016 to 2020, primary healthcare worker mobility reached its peak, in which the most significant movement occurred between township health centers and other institutions. Aside from their transition to primary medical institutions, the primary movement of grassroots health personnel predominantly directs towards secondary general hospitals, tertiary general hospitals, and secondary specialized hospitals. Since 2012, the number and mobility distance of primary healthcare workers have become noticeably larger and remained at a higher level from 2016 to 2020. The main migration of primary healthcare personnel occurred in their districts (counties). Key transition factors include gender, education, ethnicity, professional category, general practice registration, and administrative division.

CONCLUSIONS

This study provides evidence of the features of primary healthcare personnel mobility in the less developed western regions of China, in which Nanning was taken as a case study. It uncovers the factors that impact the flow of primary healthcare personnel to non-primary healthcare institutions. These findings are helpful to policy refinement and support the retention of primary healthcare workers.

Health and health system impacts of China's comprehensive primary healthcare reforms: a systematic review

China's comprehensive primary healthcare (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality healthcare services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In 13 August 2022, international databases and three Chinese databases were searched for randomized controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group and assessed impacts on expenditures, utilization, care quality and health outcomes. Study quality was assessed using Risk of Bias In Non-randomized Studies of Interventions, and results were synthesized narratively. From 49 174 identified records, 42 studies were included-all with quasi-experimental designs, except for one randomized control trial. Nine studies were assessed as at low risk of bias. Only five low- to moderate-quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilization, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N = 15) and financing reforms (N = 11) were the most studied policies, whilst policies on primary care provision (i.e. family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilization (N = 17) and improved health outcomes in people with non-communicable diseases (N = 8). Evidence on healthcare costs was unclear, and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups that accrued greater benefits (N = 8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilization, improving some health outcomes and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance universal health coverage.

Variation in quality of care by medical institute level in China: a systematic review protocol

INTRODUCTION

Quality variation has been widely witnessed and discussed in China. However, limited evidence reveals quality gaps by the medical institute level, especially between hospitals and primary care institutes. This systematic review will synthesise the available evidence on quality variation between medical institutes at different levels in China. By adopting a quality framework, we will also explore the detailed domains (structure, process and outcomes) and dimensions (safety, effectiveness, timeliness, patient-centredness, efficiency, integration and equity) of quality gaps.

METHODS AND ANALYSIS

An extensive literature search will be conducted on eight key electronic databases: MEDLINE, Web of Science, Cochrane Library, Scopus, EMBASE, ProQuest, China National Knowledge Infrastructure and WANFANG database. The Grey Matter Checklist will be used to screen relevant grey literature. The publication time limit should be before 31 December 2022 when we plan to conduct a literature search. All kinds of studies that revealed the quality difference between medical institutes at different levels will be included, no matter if quality improvement intervention is involved. All quality measures and indicators will be recorded and sorted into appropriate domains and dimensions. For those studies that took the completion rate of standard operations to assess the quality, we will also record the name of the clinical pathways, guidelines or checklists used. Two reviewers will independently perform the study selection, data extraction and quality assessment process. A narrative or quantitative synthesis will be performed based on the available data.

ETHICS AND DISSEMINATION

Ethics approval is not applicable. The results of this study will be submitted to a widely accepted peer-review journal. The findings will also be used to inform administration about quality gaps by different medical institute levels and, therefore, help them to design policies that will minimise the quality variation.

PROSPERO REGISTRATION NUMBER

CRD42022345933.

Making effective referrals happen: a theory-informed policy analysis

Effective referral is a critical element of a well-functioning health system. While having a good referral policy in place is important, equally important is its effective implementation. Using the implementation of a policy on referral of obstetric emergencies in Shanghai as a case, we illustrate the application of the 'Inhabited Institutions' analytical approach for studying policy implementation. In doing so, our study highlights how 'referral' is a quintessential systems process embedded in institutional, social and historical contexts. We show that multiple institutional logics, in the form of explicit and tacit organizing principles and assumptions, intersect to influence and shape actors' actions, sometimes with good outcomes and sometimes with poor outcomes. We reveal the embedded agency of frontline healthcare managers and providers across different levels of care. We show how frontline managers and providers, operating under conditions of uncertainties and ambiguities in organizational processes, actively draw upon their experience and network capital to creatively adapt to get referrals done in a timely manner to save lives of critically ill pregnant women. From our findings, two sets of linked implications emerge for strengthening referral systems. Given that referral often involves ill and complicated cases, getting referrals right depends on the exercise of discretion and judgement by those at the frontline to arrive at timely and workable solutions-health systems need to recognize this. We also conclude that to get referrals right, while one needs clearly defined policies and implementation processes that are locally appropriate, well understood by all concerned and easy to follow, this is not enough. In addition, explicit measures that enable the exercise of discretion and judgement at the frontline need to be locally identified and adopted.

Effect of healthcare system reforms on public hospitals' revenue structures: Evidence from Beijing, China

To reduce the heavy reliance of public hospitals on drug sales and use of advanced technologies and to contain the escalating medical expenditures, Beijing implemented two rounds of comprehensive public hospital reform in 2017 and 2019, respectively. The first round focused on separating drug sales from hospital revenue (reform1), and the second round extended to include zero markup on medical consumables and price adjustments for medical services (reform2). To estimate how these two rounds of reform have affected public hospitals' revenue structures, we used observational data of medical revenues from 2016 to 2019 covering 354 healthcare facilities. A Panel-interrupted time-series (PITS) model was used to analyze the effects. The results suggest that the reforms have changed the structure of public hospitals' revenues. The proportion of drug sales in hospital revenues fell from 43.96% in 2016 (pre-reform) to 34.08% in 2019 (post-reform); the proportions of medical consumables decreased by 0.73% after reform 2; and the proportion of medical consultation service fees increased from 15.16% in 2016 to 24.51% in 2019. PITS analysis showed that the proportion of drug sales dropped by 5.46% in the month of reform 1, and it dropped by 0.20% per month on average after reform 2(p < 0.001). The proportion of medical consumables decreased by 0.04% per month on average after reform 2 (p < 0.001). The proportion of medical consultation service increased by 7.13% in the month of reform 1, and it increased by 0.14% per month on average after reform 2(p < 0.001). Similar trends were seen in hospital revenue structures from both inpatient services and from outpatient and accident and emergency services. Thus, Beijing's reforms successfully contained rising medical expenditures and optimized hospitals' revenue structures. These reforms can provide a reference for further public hospital reforms in China and other countries with similar systems.

How Can One Strengthen a Tiered Healthcare System through Health System Reform? Lessons Learnt from Beijing, China

How one can reshape the current healthcare sector into a tiered healthcare system with clarified division of functions between primary care facilities and hospitals, and improve the utilization of primary care, is a worldwide problem, especially for the low and middle-income countries (LMICs). This paper aimed to evaluate the impact of the Beijing Reform on healthcare-seeking behavior and tried to explain the mechanism of the change of patient flow. In this before and after study, we evaluated the changes of outpatient visits and inpatient visits among different levels of health facilities. Using the monitored and statistical data of 373 healthcare institutions 1-year before and 1-year after the Beijing Reform, interrupted time series analysis was applied to evaluate the impact of the reform on healthcare-seeking behavior. Semi-structured interviews were used to further explore the mechanisms of the changes. One year after the reform, the flow of outpatients changed from tertiary hospitals to community health centers with an 11.90% decrease of outpatients in tertiary hospitals compared to a 15.01% increase in primary healthcare facilities. The number of ambulatory care visits in primary healthcare (PHC) showed a significant upward trend (P < 0.10), and the reform had a significant impact on the average number of ambulatory care visits per institution in Beijing's tertiary hospitals (p < 0.10). We concluded that the Beijing Reform has attracted a substantial number of ambulatory care visits from hospitals to primary healthcare facilities in the short-term. Comprehensive reform policies were necessary to align incentives among relative stakeholders, which was a critical lesson for other provinces in China and other LMICs.