Healthcare Reform in The People's Republic of China - Primary Care Reform

Primary Care Reform

Lu et al. reported in 2005 that China has no national primary care system, in particular general practice. The introduction of general practice in parts of urban China began in 1999. Lu et al. explain that "acceptance of general practice has been slow against the background of a strong urban tradition of hospitals as primary care providers, the widespread belief that specialists are more skilled than generalists even for minor complaints, and the perceived right of the individual to use the provider of their choice. But these attitudes are changing slowly. In several cities, notably in Zhejiang, Jiangsu, and Guangdong provinces, general practitioners (GPs) are acquiring a good local reputation and are attracting large numbers of patients."

Lu et al. responded to criticisms that general practice in China failed to perform a gate-keeping role, by stating that "such a role is virtually impossible to establish in the presence of a diversity of payment schemes including government insurance, employer-paid insurance, private insurance, community-based insurance (mostly with only part reimbursement), and out-of-pocket payment. Training and pay have not presented problems. The system of payment of GPs is similar to that of hospital practitioners - ie, a basic salary supplemented by bonuses according to performance. In popular hospitals and busy specialties, these bonuses may be up to ten times the basic salary, whereas some hospital doctors may receive only the basic salary. Likewise, GPs get a basic salary, which is topped up from patients' fees and prescriptions. Thus there are clear incentives to improve quality, hence attracting more patients and increasing income. The desire of newly-trained doctors to work in cities will ensure there will be an unlikely shortage of GPs for the foreseeable future."

There are several important problems facing health policy-makers. First, a system that keeps basic wages low, but allows doctors to make money from prescriptions and investigations, leads to perverse incentives and inefficiency at all levels. Second, as in many other countries, to develop systems of health insurance and community financing which will allow coverage for most people is a huge challenge when the population is ageing and treatments are becoming more sophisticated and expensive. Several different models have been developed across the country to attempt to address the problems.

An example of a reform model based on an international partnership approach was the Basic Health Services Project. This was implemented between 1998 and 2007 by the Government of China in 97 poor rural counties in which 45 million people live. Its aim was to encourage local officials to test innovative strategies for strengthening their health service to improve access to competent care and reduce the impact of major illness. In particular it supported county implementers to translate national health policy into strategies and actions meaningful at a local level.

In view of China managing major health system reform against a background of rapid economic and institutional change, the Institute of Development Studies outlines policy implications based on collaborative research around the Chinese approach to Health System Development. This approach includes testing innovations at local level, encouraging learning from success, and gradually building institutions that support new ways of doing things. It suggests that analysts from other countries and officials in organisations that support international health need to understand this approach if they are to strengthen mutual learning with their Chinese counterparts.