How to promote primary care in Zhejiang, China : a combined qualitative and quantitative study

Abstract

China’s recent health reforms aim to rebuild a strong primary care system through community health services (CHS) to meet its population’s escalating healthcare needs. Despite substantial government efforts to develop a good CHS system, the under-utilization of CHS has not improved. The aim of this project was to examine how to better promote primary care in the urban areas of Zhejiang, China. I explored both the general public’s and doctors’ views and attitudes towards CHS, and the impact of three health reform policies on the public’s utilization of CHS, namely health insurance schemes, the essential drug list (EDL) and the promotion of traditional Chinese medicine (TCM) in primary care. A mixed-methods approach was adopted, using individual interviews, focus group interviews and questionnaires to collect data. Samples from the general public and doctors—including primary care practitioners (PCPs) and specialists—in Hangzhou were recruited for the interviews and questionnaire surveys. In the survey with the public (n=1248), 70% of respondents preferred hospital-based outpatient services as first-contact care for diagnosing an illness, especially for pediatric patients (83.3%). Nearly two-thirds (64.1%) visited hospital outpatient clinics at least once in the year prior to the survey. The public showed a deep distrust in PCPs’ competence. Some considered PCPs as merely drug dispensers, “barefoot doctors” with 3 to 6 months’ basic medical training, “san jiao mao” (jack-of-all-trades, master of none), or “Tuo er” (a cunning agent who led patients to notorious hospitals to make money). Only 9.3% of 464 CHS users thought PCPs could handle over 75% of their medical problems. Besides, undesirable high expectations of high-tech services were common. The doctors interviewed frequently mentioned the profit orientation of health institutions, and 36.9% of the 1111 survey respondents reported a need of making profits for their institutions, leading to feelings of guilt and frustration about compromising patients’ interests. This also caused fierce market competition between CHS and hospitals. CHS was seen as underperforming in the important roles of gatekeeper, coordinator and provider of continuous care. In addition to a lack of confidence in PCPs’ competence, doctors highlighted an absence of clear operational instructions and information sharing between hospitals and community facilities which impeded PCPs from acting as coordinators. EDL means certain drugs commonly used by primary care patients are unavailable. Up to 53.1% of PCPs and 42.4% of specialists disagreed with the effectiveness of EDL in diverting patients to CHS. Strict cost controls by insurance schemes contributed to unnecessary patient visits. The ineffectiveness of insurance schemes in diverting patients to CHS was reported by 39.3% of PCPs and 49.2% of specialists. Also, TCM was increasingly utilized, partly due to its high profit margins. The gatekeeping role of CHS is still far from ideal. The profit orientation of public institutions, which may harm the development of CHS, is widespread. More radical actions are needed to remove perverse incentives and enable the CHS to function effectively as a gatekeeper in the health system. Health reform policies need careful evaluation and refinement to reduce barriers to CHS development.