The health system and health impacts of China’s comprehensive Primary Health Care reforms since 2009
File(s)
Author(s)
Cai, Chang
Type
Thesis or dissertation
Abstract
Background Comprehensive primary health care (PHC) reforms are infrequently and often poorly studied in low- and middle-income countries. China launched a two-stage, comprehensive PHC reforms (in 2009 and 2015, respectively) to increase the accessibility, affordability, and equity of primary care services. The PhD project aims to evaluate the reform impacts on the health system and health outcomes.
Methods Three components were conducted: 1). A systematic review of the existing studies on the reforms, with quality assessment and narrative synthesis. 2). A difference-in-differences (DiD) study using panel data from 31 provinces (2010-2019) estimating the 2015 reform impacts on PHC inputs, primary care utilisation, costs, and mortalities, and potential pathways. 3). A DiD study using cohort data (age ≥ 45, N=43,644, 2011-2018) estimating the 2015 reform impacts on primary care utilisation, hospitalisations, out-of-pocket expenditures(OOPEs), and self-reported health.
Results The existing evidence shows that the reforms since 2009 were associated with increased primary care utilisation (N=17), some improved health among people with non-communicable diseases (N=8), and some improved equity(N=8). Evidence on health care costs was mixed. Financial protection and care quality were underexamined. The panel analysis found that the 2015 reforms were associated with increased utilisation of family physicians and prenatal care, higher hospital costs for outpatient check-ups and drugs, and a reduced maternal mortality ratio. The reforms mainly affected under-resourced regions. The cohort analysis found that The 2015 reforms had a short-lived impact on increasing primary care utilisation, OOPEs, and self-reported health. Hospitalisations were not affected. The increased utilisation was mainly among rural/lower-income populations.
Conclusion China’s PHC reforms have made some progress in increasing the equitable use of primary care and improving the health of high-risk populations. System-wide reforms are needed to shift away from hospital domination, enhance financial protection and care quality, and improve population health and health equity.
Methods Three components were conducted: 1). A systematic review of the existing studies on the reforms, with quality assessment and narrative synthesis. 2). A difference-in-differences (DiD) study using panel data from 31 provinces (2010-2019) estimating the 2015 reform impacts on PHC inputs, primary care utilisation, costs, and mortalities, and potential pathways. 3). A DiD study using cohort data (age ≥ 45, N=43,644, 2011-2018) estimating the 2015 reform impacts on primary care utilisation, hospitalisations, out-of-pocket expenditures(OOPEs), and self-reported health.
Results The existing evidence shows that the reforms since 2009 were associated with increased primary care utilisation (N=17), some improved health among people with non-communicable diseases (N=8), and some improved equity(N=8). Evidence on health care costs was mixed. Financial protection and care quality were underexamined. The panel analysis found that the 2015 reforms were associated with increased utilisation of family physicians and prenatal care, higher hospital costs for outpatient check-ups and drugs, and a reduced maternal mortality ratio. The reforms mainly affected under-resourced regions. The cohort analysis found that The 2015 reforms had a short-lived impact on increasing primary care utilisation, OOPEs, and self-reported health. Hospitalisations were not affected. The increased utilisation was mainly among rural/lower-income populations.
Conclusion China’s PHC reforms have made some progress in increasing the equitable use of primary care and improving the health of high-risk populations. System-wide reforms are needed to shift away from hospital domination, enhance financial protection and care quality, and improve population health and health equity.
Version
Open Access
Date Issued
2024-05-03
Date Awarded
2024-08-01
Copyright Statement
Creative Commons Attribution NonCommercial Licence
License URL
Advisor
Hone, Thomas
Millett, Christopher
Publisher Department
School of Public Health
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)