The current status and challenges of community general practitioner system building in China

Equity and trends in general practitioners' allocation in China: based on ten years of data from 2012 to 2021

BACKGROUND

General practitioners (GP) are the gatekeepers of residents' health, 2021 is the 10th year of the establishment of the GP system in China. This study aims to assess the equity and trends of GP allocation in China from 2012 to 2021, summarize the efforts and progress of GPs in China during the decade, predict the development trend of GPs in mainland China in the next 5 years to provide a reference for regional health planning and rational allocation of GPs in China.

METHODS

Data from 2012 to 2021 on GPs in 22 provinces, 5 autonomous regions, and 4 municipalities directly under the central government in mainland China (excluding Hong Kong, Macao, and Taiwan) are collected by us. Gini coefficient, Lorenz curve and health resource agglomeration degree (HRAD) were used to analyze the equity of the allocation of GPs in China from different dimensions, a Grey prediction model was used to forecast the number of GPs in 2022-2026.

RESULTS

The number of GPs in mainland China increased from 109 794 to 434 868 from 2012 to 2021, with 3.08 GPs per 10 000 people in 2021. The Gini coefficient of GPs allocation by population in China decreased from 0.312 to 0.147 from 2012 to 2021, while the Gini coefficient of geographic dimension remained between 0.700 and 0.750. Compared with the degree of curvature of the Lorenz curve in the geographic dimension, the degree of curvature of the population and economic dimension were smaller. In 2021, the HRAD in the Eastern region was 4.618, the Central region was 1.493, with different degrees of imbalance among regions, the HRAD/PAD (population agglomeration degree) in the Eastern, Central and Western regions were 1.196, 0.880 and 0.821, respectively. GPs in the Eastern region is still concentrated, while the Central and Western regions were at a similar level, GPs were more scarce. The GM (1,1) model predicts that the number of GPs in mainland China will reach about 720 000 in 2026, the number of GPs per 10 000 people will reach 4.9.

CONCLUSION

After a decade of development, the number of GPs in China has increased significantly. It has reached the goal of the GP system when it was first established. However, the equity of the geographical dimension, both in terms of Gini coefficient and HRAD, has great differences between different regions. The average Gini coefficient at the geographic dimension is 0.723. The average HRAD index was 4.969 in the East and 0.293 in the West. The Western region has the problem of insufficient GP allocation in both population and geographical dimension. In the future, the number of GPs in China will continue to grow rapidly with the support of policies. The "2030" goal, proposed in 2018, is expected to be achieved by 2026. Due to certain factors (such as COVID-19), the actual situation may be different from the predicted results.

The negative factors influencing the career intention of general practice trainees in eastern China: a qualitative study

BACKGROUND

There is an acute shortage of general practitioners (GPs) in China, and GP trainees seem to be less willing to develop their career as a GP. This study aimed to investigate negative factors influencing the career intention of GPs in eastern China from the perspective of trainees taking standardized residency training, as to identify the barriers of GP trainees becoming registered GPs, and to provide a policy-making basis for GP recruitment and retention.

METHODS

A qualitative description design by the purposive sample was carried out in two training bases of Jinan and Qingdao in eastern China. Face-to-face, in-depth, semi-structured interviews were conducted, audiotaped, and transcribed using thematic analysis.

RESULTS

Twenty-one trainees participated in this study. Thematic analysis generated five major themes: (1) low social recognition, (2) low professional identity, (3) low remuneration level, (4) imperfect training system, and (5) influence of policy factors.

CONCLUSIONS

Our results identified various negative factors influencing the career intentions of trainees. In order to overcome the hurdles and increase the attractiveness of GP, it is recommended that the government and the public should create a supportive environment, which can be beneficial to the construction and development of GP.

Association of Continuity of General Practitioner Care with Utilisation of General Practitioner and Specialist Services in China: A Mixed-Method Study

Background: Continuity of general practitioner (GP) care, widely known as the core value of high-quality patient care, has a positive association with health outcomes. Evidence about the relationship between continuity and health service utilisation has so far been lacking in China. This study aimed to analyse the association of continuity of GP care with utilisation of general practitioner and specialist services in China. Method: A cross-sectional mixed methods study was conducted in 10 urban communities in Hangzhou. Quantitative data were collected from a random sample of 624 residents adopting the self-developed questionnaire. Measurement of continuity of GP care included informational continuity (IC), managerial continuity (MC) and relational continuity (RC). With adjustment for characteristics of residents, multivariate regression models were established to examine the association of continuity of GP care with the intention to visit GP, frequency of GP and specialist visitations. Qualitative data were collected from 26 respondents using an in-depth interview, and thematic content analysis for qualitative data was conducted. Results: Quantitative analysis showed that the IC was positively associated with the intention to visit GP and frequency of GP visitations. Those people who gave a high rating for RC also used GP services more frequently than their counterparts. MC was negatively associated with frequency of specialist visitations. Qualitative analysis indicated that service capabilities, doctor-patient interaction and time provision were regarded as three important reasons why patients chose GPs or specialists. Conclusions: Overall, high IC and RC are independently associated with more GP service utilisation, but a high MC might reduce specialist visitations. Continuity of GP care should be highlighted in designing a Chinese GP system.

Association between contact with a general practitioner and depressive symptoms during the COVID-19 pandemic and lockdown: a large community-based study in Hangzhou, China

OBJECTIVES

To determine the association of general practitioner (GP) contact with depressive symptoms during the COVID-19 pandemic and lockdown in China.

DESIGN

In April 2020, a follow-up survey was conducted on the basis of a baseline survey conducted between October 2018 and May 2019.

SETTING

The survey was embedded in the Stanford Wellness Living Laboratory-China (WELL China) study, an ongoing prospective community-based cohort study during 2018-2019.

PARTICIPANTS

The survey was conducted by telephone interview among 4144 adult urban residents participating in the WELL China study at baseline. We collected information on sociodemographic characteristics, depressive symptoms and GP contact during the lockdown period (February to March 2020).

PRIMARY AND SECONDARY OUTCOME MEASURES

Depressive symptoms were measured using the WHO-Five Well-being Index, comprising five questionnaire items that briefly indicate psychological well-being. Logistic regression models were applied to assess the association between GP contact and depressive symptoms.

RESULTS

In total, 3356 participants responded to the survey; 203 were excluded owing to missing data on depressive symptoms, leaving 3153 participants in the present study. During lockdown, 449 participants had GP contact. GP contact was significantly negatively associated with prevalent depressive symptoms (OR, 0.67; 95% CI 0.51 to 0.89; p<0.01) and incident depressive symptoms (OR 0.68; 95% CI 0.51 to 0.93; p<0.05). Stratified analysis showed a significant negative association between depressive symptoms and GP contact in individuals who were 45-64 years old (p<0.01), had a middle or high education (p<0.01) and had self-reported non-communicable diseases (p<0.05).

CONCLUSIONS

Contact with GPs during the COVID-19 pandemic and lockdowns may have a negative association with depressive symptoms in community-dwelling populations. Given the possibility of further surges in COVID-19 infections, GPs' contact in the community should be enhanced.

Who is willing to participate in and provide Family Doctor Contract Service?: A cross-sectional study based on the medical staff's perspective in China

China encourages medical staff from non-primary hospitals (higher-level hospitals) to participate in and provide Family Doctor Contract Service (FDCS) due to a lack of primary medical resources in community health service centers. This study aims to explore the factors affecting the willingness of family doctor contracting from the tertiary hospital medical staff's perspective. An anonymous self-administered survey was conducted among the medical staff from tertiary hospitals in Hangzhou, Zhejiang Province. Information of the socio-demographic characteristics, the willingness of participating in FDCS and its related reasons, and factors that might affect willingness were investigated. A multivariate logistic regression was used to identify the statistically significant variables associated with willingness. A total of 346 medical staff were recruited in the survey, and 37.86% of them were willing to participate in and provide FDCS. Medical staff with the following characteristics had stronger will: (1).. with higher education level; (2).. having better knowledge with family doctor; (3).. being more attracted by the national policy of FDCS; (4).. thinking it help for income increase. The majority of willing doctors (25.95%) believed that participating in FDCS could help them achieve their personal value, and the reason chosen most for unwilling reason was “low income and unrealized personal value (32.21%).” It is necessary for the government to establish the essential matching mechanisms to guarantee the development of the family doctor, including increasing the final financial support for primary health facilities, and developing the national incentive mechanism for family doctors.

From Mao to McDonaldization? Assessing the rationalisation of health care in China

China's 2009 health care reform agenda has been referred to as one of the most ambitious health policy programmes in modern history. Significant investment has combined with new structures, incentives, and regulations that have aimed to improve access, as well as gain greater control over a health care market much criticised for putting profit before patients. A range of health services research has been undertaken to analyse these efforts. Sociological perspectives have also been documented yet up to now a review and synthesis combining these various contributions has not been undertaken. By drawing on the lens of McDonaldization, the paper presents a narrative review that analyses the extent to which China's 2009 reform agenda has increased efficiency, calculability, predictability, and control over service provision. The review identifies elements of McDonaldization within China's 2009 reform agenda, however, notable gaps remain. In response to the limits of McDonaldization as a lens for understanding China's health care reform, the paper calls for alternative perspectives that are better able to understand the sociocultural dynamics shaping service provision, as well as an interdisciplinary research agenda that is able to generate new insights and understanding regarding health care in China.

The Awareness and Attitude of Contracted Service Among General Medical Practitioners in Community Health Service Centers in Urban China: A Cross-Sectional Study

This study aims to explore the attitude, willingness, and satisfaction with contracted service (CS) among staff in community health service (CHS) centers in urban China and to explore the associated factors of satisfaction with CS. From August 2016 to July 2017, five CHS centers in three provinces of China were selected. Setting-level information was collected by official document review; and personal information on demographic characteristics, awareness, willingness, and attitude of CS among staff was collected by questionnaire survey. Univariate and multivariable logistic regression models were fitted to explore the associated factors of satisfaction with CS. Multiple correspondence analysis (MCA) was used to visually demonstrate the correlations among category data related with satisfaction with CS. The CS signing rates were 30.78, 12.72, 22.20, 14.32, and 21.19% in the five CHS centers. A total of 286 staff included family doctors (40.91%), nurses (31.12%), and others (27.97%) completed the survey. For the sense of self-worth, 86.01% (246/286) participants hold a positive attitude. The predominant barrier of CS signing was caused by the work pressure due to CS performance assessment (48.60%, 139/286). About 30% of family doctors and nurses reported a heavy work pressure, and more than 30% of doctors had great feeling of fatigue. Notably, 51.69% family doctors would like to change their job in the future. Compared with other staff, family doctors were more likely to be unsatisfied with CS (OR: 2.793, 95% CI: 1.155–6.754, p = 0.022). Participants in Sichuan province have lower satisfaction than other places. The MCA yielded similar factors consistent with multivariable results of clustering with different levels of CS satisfaction. Our study revealed that the CS coverage and satisfaction among staff from the primary healthcare system varied geographically and are associated with professional field, workload, and pressure. Measures that aim to promote the stability of primary care human resource should be considered in the future.

Internet-based patient- primary care physician-cardiologist integrated management model of hypertension in China: study protocol for a multicentre randomised controlled trial

INTRODUCTION

The control rate of hypertension is low in China, especially in rural, western and minority areas. This is related to poor medical skills among physicians in primary care institutions and low levels of trust among patients. However, primary healthcare institutions are the main battleground for the prevention and treatment of hypertension. It is worth exploring how to most effectively integrate patients, primary care physicians and cardiologists in tertiary hospitals, to build a long-term mechanism for the prevention and treatment of hypertension. In this study, we aim to evaluate the clinical effectiveness and conduct a health economic evaluation of an internet-based patient-primary care physician-cardiologist integrated management model of hypertension in areas of China with different socioeconomic levels.

METHODS AND ANALYSIS

This is a 12-month, multicentre, randomised controlled trial involving patients with hypertension in urban communities and rural areas of Sichuan Province, China. Each primary healthcare institution will cooperate with their tertiary hospital through the Red Shine Chronic Disease Management System (RSCDMS). Patients will be randomly assigned 1:1 to two groups: (1) a traditional care group; (2) an intervention group in which primary care physicians and cardiologists can share patient data and manage patients together through the RSCDMS. Patients can upload their blood pressure (BP) values and communicate with physicians using the system. The primary outcome is the change in systolic BP over a 12-month period. Secondary outcomes are changes in diastolic BP, BP control rate, values of 24-hour ambulatory BP monitoring, difference in cost-effectiveness between the groups, patient satisfaction, medication adherence and home BP monitoring compliance. All data will be recorded and stored in the RSCDMS and analysed using IBM SPSS V.26.0.

ETHICS AND DISSEMINATION

This study has been approved by the Biomedical Research Ethics Committee of the West China Hospital of Sichuan University in Sichuan, China (No. 2020-148). Written informed consent will be obtained from all participants. The results of this study will be disseminated to the public through academic conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000030677.

Cost-effectiveness analysis of different hypertension management strategies in a community setting

Self-management schemes and mobile apps can be used for the management of hypertension in the community, but the most appropriate patient population is unknown. To explore whether the Chinese Health Literacy Scale (CHLSH) can be used to screen for appropriate patients with hypertension for self-management and to evaluate the clinical effectiveness and health economic evaluation of three hypertension management schemes. This was a prospective study performed from March 2017 to July 2017 in consecutive patients with primary hypertension and of 50-80 years of age from the Jinyang community, Wuhou District, Chengdu. The CHLSH was completed and the patients were classified into the high (n = 283) and low (n = 315) health literacy groups. The patients were randomly divided into the self-management, traditional management, and mobile app management groups. The high-health literacy group was selected to construct the cost-effectiveness decision tree model. Blood pressure control rate and the quality-adjusted life years (QALYs) were determined. At the end of follow-up, the success rate of self-management was 83.4%. The costs for 6 months of treatment for each patient with hypertension in the self-management, traditional management, and mobile app groups were 1266, 1751, and 1856 yuan, respectively. The costs required for obtaining 1 QALY when managing for 6 months were: 30,869 yuan for self-management; 48,628 yuan for traditional management; and 43,199 yuan for the mobile app. The CHLSH can be used as a tool for screening patients with hypertension for self-management. The cost-effectiveness of self-management was optimal.

Perceptions, behaviours, barriers and needs of evidence-based medicine in primary care in Beijing: a qualitative study

Background

Evidence-based medicine (EBM) is gradually being recognized worldwide as an important clinical skill and plays an important role in health care. Although the concept has successfully spread in the health care field, EBM still has not been widely incorporated into clinical decisions in primary care due to potential barriers. This study aimed to explore the views, experiences and obstacles of general practitioners (GPs) regarding the use EBM in their daily clinical practices in Beijing.

Methods

We performed a qualitative study with GP focus groups. Thirty-two GPs working in 26 community health service centres in 7 districts in Beijing were recruited. Four focus group sessions with 32 GPs were conducted in a meeting room at the Capital Medical University from January to February in 2018 in Beijing. All sessions were audio-recorded, transcribed and analysed for themes using an inductive content analysis approach.

Results

GPs believed that EBM could help them enhance the quality of their clinical practice. The most common EBM behaviour of GPs was making clinical decisions according to guidelines. The barriers that limited the implementation of EBM were patients’ poor compliance, lack of time, lack of resources, inadequate skills or knowledge, and guideline production problems. The first need for GPs was to participate in training to enhance their skills in practising EBM.

Conclusions

To practise EBM in general practice, integrated interventions of different levels need to be developed, including enhancing GPs’ communication skill and professional competency, training GPs on the implementation of EBM, employing more staff to reduce GPs’ workloads, providing adequate resource support, and developing evidence-based clinical guidelines for GPs.

Medical and socio-demographic characteristics associated with patient-perceived continuity of primary care: A cross-sectional survey in Hangzhou, China

BACKGROUND

This study measured the perceived continuity of general practitioner (GP) care from the patient's perspective and identified the associated factors.

METHODS

A cross-sectional survey was carried out on 624 patients in community health care centres in Hangzhou, China. A self-designed Likert scale was used to measure patients' perceptions on informational, managerial, and relational continuity of GP care. An average score for three types of continuity ranging from 0 to 100 was calculated. Linear regression models were developed to determine the factors influencing continuity.

RESULTS

Average rating scores of 57.73 (±15.31), 50.74 (±17.18), 61.61 (±18.07), and 63.57 (±17.40) were found for total, informational, managerial, and relational continuity of care, respectively. Older patients reported a more positive rating on all types of continuity. Income was negatively associated with managerial continuity. The factors affecting informational, relational, and total continuities included chronic diseases, walking distance to nearest community health centres, signing a contract with a GP, and knowing the names of contracted GPs.

CONCLUSION

Patients' perception of continuity of GP care remains at a low level, especially for informational continuity. The varied association between continuity of care and identified factors suggests that targeted actions should be considered for improving the quality of GP services.

What Does the Chinese Public Care About with Regard to Primary Care Physicians: Trustworthiness or Competence?

Background and Objective: China has launched a series of reforms to enhance primary care. The aims of these reforms are to strengthen the functionality of primary care to encourage patients to use primary care. Patients’ trust in physicians is important in clinical medicine; however, little is known about how Chinese patients’ preferences relate to their trust in primary care physicians. This study’s objectives are to measure the Chinese public’s trust in primary care physicians and to characterize reasons of their preferences for health care. Materials and Methods: This quantitative study comprises a face-to-face survey with a convenience sample (n = 273) of people visiting community health centers or stations (CHCSs) in Wuhan, China. We measured the patients’ preferences for the different level of hospitals and their trust in physicians, as well as the reasons of the patients’ preferences, using a Chinese version of the Wake Forest Physician Trust Scale and other variables (such as demographics, health status, and hospital preference). Results: Approximately two thirds (68.6%) of the participants had experienced a mild or chronic disease in the year before the survey, but only 26.4% preferred to visit CHCSs in such cases. The negative factors related to this lack of preference are the physicians’ competence (odds ratio [OR] = 0.250), the medical equipment (OR = 0.301), and the popularity of hospitals (OR = 0.172). The positive factors were ease of access (OR = 2.218) and affordability (OR = 1.900). The participants expressed a moderate trust in physicians in CHCSs (score of 3.02 out of 5). There is no association between the patients’ trust and their hospital preference (r = 0.019, p = 0.859). Of the participants, 92 suggested that the physicians in CHCSs should improve in terms of their competence (n = 53), attitude (n = 35), and/or medical ethics (n = 16). Conclusions: This study’s results suggest that patients consider improving physicians’ competence to be more important and urgent than improving those physicians’ trustworthiness in terms of reconstructing Chinese primary care. Improving the physicians’ competence would not only reduce the barriers that patients experience regarding CHCSs, but would also increase their trust in the physicians.

General practice for the poor and specialist services for the rich: inequality evidence from a cross-sectional survey on Hangzhou residents, China

Background

Inequalities in health care services are becoming an increasing concern in the world including in China. This study measured the income-related inequalities of residents in Hangzhou of China in access to general practice and specialist care and identified socioeconomic factors associated with such inequalities.

Methods

A cross-sectional questionnaire survey was conducted on 1048 residents in ten urban communities in Hangzhou, China. The percentage and frequency of respondents visiting general practice (GP) and hospital specialist clinics over the past four weeks prior to the survey were estimated. Income-related inequalities in access to these services were measured by the concentration index. Logistic regression and Poisson regression models were established to decompose the contributions of socioeconomic factors (residency, income, education, marital status, and social health insurance) to the inequalities in the probability and frequency of accessing these services, respectively, after adjustment for the needs factors (age, sex and illness conditions).

Results

The GP services were in favor of the poor, with a concentration index of − 0.0464 and − 0.1346 for the probability and frequency of GP visits, respectively. In contrast, the specialist services were in favor of the rich, with a concentration index of 0.1258 and 0.1279 for the probability and frequency of specialist visits, respectively. Income is the biggest contributor to the inequalities, except for the frequency of visits to specialists in which education played the greatest role.

Conclusions

Income-related inequalities in GP and specialist care are evident in China. Policy interventions should pay increasing attention to the emergence of a two-tier system, potentially enlarging socioeconomic disparities in health care services.

Electronic supplementary material

The online version of this article (10.1186/s12939-019-0966-6) contains supplementary material, which is available to authorized users.

Factors determining intention to leave among physicians in tertiary hospitals in China: a national cross-sectional study

OBJECTIVE

The reasons that physicians leave the institutions have not been extensively studied. We aimed to evaluate these reasons, which include the desire to work at another hospital or the intention to make a career change, among physicians in tertiary hospitals in China and explore the associations between the individual-level and organizational-level factors related to these two reasons for leaving.

METHODS

We conducted a national survey of 136 tertiary hospitals across all 31 provinces in China between December 2017 and January 2018. A total of 20 785 physicians were selected to self-report on the two evaluated reasons related to physicians' intent to leave. A univariate analysis and multilevel regression model were applied to evaluate the factors associated with intention to leave.

RESULT

In all, 10.4% of the participating physicians had thought about working at another hospital, and 20.5% intended to leave to make a career change. At the hospital level, the government subsidy per bed (OR=0.88, 95% CI: 0.86 to 0.98 and OR=0.91, 95% CI: 0.90 to 0.99), personnel funding per capita (OR=0.86, 95% CI: 0.76 to 0.96 and OR=0.80, 95% CI: 0.73 to 0.88) and the number of physicians per bed (OR=0.83, 95% CI: 0.81 to 0.86 and OR=0.89, 95% CI: 0.81 to 0.92) were negatively associated, while the number of hospital-level medical disputes (OR=1.04, 95% CI: 1.03 to 1.05 and OR=1.06, 95% CI: 1.01 to 1.11) was positively associated with both reasons for leaving. At the individual level, income (OR=0.74, 95% CI: 0.71 to 0.79 and OR=0.88, 95% CI:0.83 to 0.92) and job satisfaction (OR=0.18, 95% CI: 0.17 to 0.20 and OR=0.16, 95% CI: 0.15 to 0.18) acted as preventive factors against both reasons for leaving, while work hours per week (OR=1.11, 95% CI: 1.06 to 1.17 and OR=1.23, 95% CI: 1.19 to 1.28) and medical dispute (OR=1.49, 95% CI:1.35 to 1.65 and OR=1.77, 95% CI: 1.64 to 1.91) acted as promotive factors.

CONCLUSIONS

Although the intention to leave is not prevalent among physicians in tertiary hospitals in China, providing more organisational support and a better occupational environment may promote retention among physicians.

Exploring the needs and possibilities of physicians' continuing professional development - An explorative qualitative study in a Chinese primary care context

BACKGROUND

One component of the 2009 Chinese health care reform plan is to train general practitioners to improve the delivery of primary care services. This continuing professional development is expected to further improve the physicians' competencies to be general practitioners in primary care. Augmented reality-a combination of virtual information and the real environment-may enhance general practitioners' continuing professional development by allowing their learning experiences to overlap with their workplace practice.

OBJECTIVE

To explore the needs, opportunities, and challenges involved in continuing professional development for Chinese physicians becoming competent general practitioners within primary care, with a special focus on the possibilities of applying augmented reality.

METHODS

This study used a qualitative approach with semi-structured face-to-face interviews. Two managers and thirteen physicians (from four community health centers and stations) participated. The data were analyzed using a thematic inductive analysis approach.

RESULTS

Based on our interviews, most of the physicians were not fully trained as general practitioners but still assumed the duties of that position; they were supposed to eventually become fully trained in line with the reforms of the Chinese primary care system. However, they reported a lack of in-service training opportunities to fulfill this goal. Even those who said that they had such opportunities perceived the efficacy of that training as being poor. The managers and most of the physicians reacted positively to the idea of using augmented reality in continuing professional development, and they suggested antibiotics treatment, surgery, and emergency care as learning areas in which augmented reality could be applied.

CONCLUSIONS

Due to the Chinese reforms of the primary care system, both managers and the physicians themselves expect general practitioners to become qualified by engaging in continuing professional development. Both groups also regarded augmented reality as a potentially useful tool.

Legal reflections on the evolving role of general practitioners in China's primary care: an assessment of regulatory strategies

Aim

To assess the regulation of the Chinese healthcare system in assisting a nationwide implementation of general practitioner (GP) services.

Background

Along with the perennial problems of unaffordable and inequitable healthcare, a rapidly ageing population and the increasing burden of non-communicable diseases pose challenges to the Chinese healthcare system. Recognising these challenges and to satisfy people’s demands for more and better healthcare, China has initiated a plan, named ‘Healthy China 2030’, based on the findings from a two-year joint study by the World Health Organization (WHO) and the World Bank Group (WBG) in collaboration with Chinese agencies. The Chinese healthcare plan, officially approved in 2016, is an attempt to use the people-centred, integrated care (PCIC) model recommended by the WHO and WBG to shape the Chinese healthcare system. In accordance with PCIC, China began the implementation of gatekeeping primary care by introducing GP services to local communities.

Methods

A comparative analysis was employed to point out the importance of introducing GP services. A systematic assessment was carried out to evaluate the regulatory sector of the Chinese healthcare system, including a critical review of related legal norms and a theoretical exploration of external impediments (eg, cultural attitudes, government capacity and interest groups).

Findings

Results demonstrate that the current regulatory sector of the Chinese healthcare system needs to be improved in order to assist the nationwide implementation of GP services and to strengthen its gatekeeping role. Major deficiencies include the problematic relationship between legal norms and health policies, the lack of effective and consistent new legislation, the low rate of social acceptance, and lack of support from agencies. To address those challenges, this paper recommends that preliminary efforts be devoted, in part, to two changes in the legal structure: enacting a specific law, and creating an independent regulatory oversight body.

Demand and Signing of General Practitioner Contract Service among the Urban Elderly: A Population-Based Analysis in Zhejiang Province, China

This study aims to examine whether the urban elderly in the Zhejiang Province of China signed contracts with their general practitioner (GP) based on their health service needs, and to further identify the determinants of their demand and signing decisions. A community-based cross-sectional study was conducted in 16 community health service (CHS) institutions in Zhejiang Province, China. The urban elderly over 60 years of age were enrolled when visiting the sampled CHS. Baseline characteristics were compared between participants using Chi-Square tests for categorical variables. Univariate and multivariable logistic regression analyses were used to identify determinants of the GP contract service demand and signing decisions, respectively. Among the 1440 urban elderly, 56.67% had signed contracts with their GP, and 55.35% had a demand of the GP contract service. The influencing factors of demand were a history of diabetes or cardiovascular disease (OR = 1.33, 95% CI, 1.05–1.68); urban resident basic medical insurance (URBMI) vs. urban employee basic medical insurance (UEBMI) (OR = 1.96, 95% CI, 1.46–2.61); and middle-income vs. low-income (OR = 0.67, 95% CI, 0.50–0.90 for RMB 1001–3000; OR = 0.59, 95% CI, 0.39–0.90 for RMB 3001–5000). Having a demand for the GP contract service was the strongest determinant of signing decisions (OR = 13.20, 95% CI, 10.09–17.27). Other factors also contributed to these decisions, including gender, caregiver, and income. The urban elderly who had signed contracts with GPs were mainly based on their health care needs. Elderly people with a history of diabetes or cardiovascular disease, as well as those with URBMI, were found to have stronger needs of a GP contract service. It is believed that the high-income elderly should be given equal priority to those of low-income.

Mental health literacy about schizophrenia and depression: a survey among Chinese caregivers of patients with mental disorder

OBJECTIVE

To investigate the knowledge of schizophrenia and depression among caregivers of patients with mental disorder in China.

METHOD

A convenience sample of 402 caregivers at the Department of Psychiatry of a general hospital in China was investigated (response rate 95.7%), using vignettes based investigation methodology.

RESULTS

The number of caregivers using the term "depression" to describe the depression vignette was 43.6%, which was significantly higher than the number of caregivers using the term "schizophrenia" to describe the schizophrenia one (28.5%). A high percentage of caregivers believed that "psychiatrist", "psychologist" and "close family members" would be helpful, and the top three most helpful interventions were "becoming more physically active", "getting out and learning more" and "receiving psychotherapy". The number of caregivers endorsed "antipsychotics" and "antidepressants" as helpful for the schizophrenia and the depression vignettes were 82.0 and 80.7%, respectively. Regarding the causes of mental illness, items related to psychosocial factors, including "daily problems" and "work or financial problems", and "weakness of character" were highly rated, with half considered genetic or chemical imbalance causes.

CONCLUSION

Caregivers expressed a high knowledge about treatments and interventions of mental disorders. But there are still some areas, particularly regarding the recognition and causes of mental disorders, that are in need of improvement. This is particularly the case for schizophrenia.

The development of urban community health centres for strengthening primary care in China: a systematic literature review

INTRODUCTION

This review outlines the development of China's primary care system, with implications for improving equitable health care.

SOURCES OF DATA

Government documents, official statistics, and recent literature identified through systematic searches performed on NCBI PubMed.

AREAS OF AGREEMENT

Community health centres (CHCs) are being developed as the major primary care provider in urban China, with laudable achievements. The road towards a strong primary care-led system is promising but challenging.

AREAS OF CONTROVERSY

The effectiveness in improving equitable care through the expansion of primary care workforce and redesign of the social medical insurance system warrants further exploration.

GROWING POINTS

Healthcare disparities exist in the health system wherein universal health coverage and gatekeepers have not yet been established.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to provide solutions for strengthening the leading role of CHCs in providing equitable care in response to population ageing and multimorbidity challenges.