Primary care in China before the introduction of GP services

The current Chinese healthcare system is a hospital-based delivery one where public hospitals, as ‘one-stop shops’, take care of the majority of healthcare demands. At the local level, primary care is supposed to be guaranteed by community health centres (CHCs) and community health stations (CHSs) in urban China, and by township health centres and village health stations in rural areas (Bhattacharyya et al., Reference Bhattacharyya, Delu, Wong and Bowen2011). These medical institutions should, in principle, serve as the gatekeepers to hospitals and specialised medical care, but in reality they fail to play this role.

This ‘failure’ is partially because patients in China can access walk-in services in public hospitals without a referral letter. Even worse, two factors aggravate the problem. One is the current Chinese health insurance scheme, which has covered over 95% of the Chinese population since 2012 (Meng et al., Reference Meng, Yang, Chen, Sun and Liu2015: 78). It consists of multiple schemes: the Urban Employee Basic Health Insurance (1998), the New Rural Cooperative Medical Scheme (2003), the Urban Resident Basic Health Insurance (2007), and the Medical Financial Assistance System (2012). In general, these schemes prioritise the reimbursement of inpatient care over outpatient care (Xiao et al., Reference Xiao, Long, Tang and Tang2014). Furthermore, the reimbursement rates of these schemes differ between them. The priority of reimbursement and the different reimbursement rates drive patients to seek inpatient care provided by public hospitals without considering whether it is necessary or not, which, in turn, results in a comparatively low rate of outpatient care provided by the community-based medical institutions. Although the community-based medical institutions also provide limited inpatient care, their major function still focuses on expanding the accessibility of outpatient care. The other impediment to discouraging hospital use concerns the quality of medical services. Compared with the community-based medical institutions, public hospitals are believed to have advanced facilities and better-educated medical professionals. Naturally patients demand high-quality medical services. The lower level of trust in the quality of medical services provided by medical institutions, such as CHCs, causes patients to hesitate to access community resources as their ‘first contact care’ (Bhattacharyya et al., Reference Bhattacharyya, Delu, Wong and Bowen2011: 179).

The combination of easy access to public hospitals and distrust in the quality of community care results in a tricky dilemma: public hospitals are overwhelmed with patients, while community-based medical institutions receive and treat fewer patients. To tackle the imbalance, public hospitals used to cut the number of beds, rather than cooperate with the community-based medical institutions. Unsurprisingly, cutting beds worsened the situation by causing inaccessibility of medical services, particularly tertiary care, and escalating medical expenses.

The public hospital dilemma was exacerbated by ‘drug mark-ups’ (The World Bank Group et al., Reference Wiley2016), which refers to the system by which ‘hospitals receive kickbacks from drug companies for prescribing their products’ (Yip and Hsiao, 2008: 463). This system gives health professionals financial incentives to over-prescribe drugs with high-profit margins. Even worse, the problem of over-prescription results in some patients’ resistance to certain drugs and increases tensions in the doctor–patient relationship (Yip and Hsiao, Reference Yip and Hsiao2009a; Reference Yip and Hsiao2009b; Ling et al., Reference Ling, Liu, Lu and Wang2011).

The traditional hospital-based delivery system needs to be changed, with special attention devoted to improving preventive care. In this regard, gatekeeping primary care is of vital importance and should be addressed as the top concern. Either as a supplement or an alternative to the current system of community-based healthcare services, GP services represent a step forward, and should be introduced in China in line with the PCIC model.

A brief overview of the GP system

Under current conditions in China, the GP system refers to a small group of medical professionals who provide basic medical care, public health and any contractual health management services (National Health and Family Planning Commission, 2016). Regardless of whether the GP is considered a supplement or an alternative to community-based medical institutions, how will the GP system be characterised?

Table 1 outlines GP services and compares them with community-based healthcare services. As shown in Table 1, GP services should include, but not be limited to, ‘common diseases management; immunisation and primary community health prevention; rehabilitation and family planning’ (Kong and Yang, Reference Kong and Yang2015: 89). Furthermore, the qualified GP should, in principle, be fully educated and trained to provide these services, but the system currently permits practising specialists and medical professionals with a background in Chinese medicine to be GPs, in order to address the shortage (Bhattacharyya et al., Reference Bhattacharyya, Delu, Wong and Bowen2011). Moreover, medical expenses should be covered by health insurance mechanisms, the public health budget and patient co-payments. In addition, the regulatory strategy should adopt incentive schemes to encourage patients to use the GP as the first contact for healthcare, and should rely on the power of the local communities to monitor and assess the performance of these doctors. Leadership should also be clarified and strengthened by smoothing communication and fostering collaboration among different government agencies, with an appropriate division of labour. Last but not least, an information-sharing system and an effective referral network are required to improve the performance of GPs.

Table 1 Comparative analysis of the current community-based healthcare system and the general practitioner (GP) services under the people-centred, integrated care (PCIC) model

CHC=community health centres; CHS=community health stations; THC=township health centres; VHS=village health stations.

^a National Health and Family Planning Commission of the P. R. China (2016).

^b There are roughly three models of collaboration between hospitals and community-based medical institutions: Loose Collaboration Model, Medical Consortium Model, and Direct Management Model. The above three traits are generated from the Loose Collaboration Model since it is employed the more often than the other two models. See Xu et al. (Reference Zhang, Bossert, Mahal, Hu, Guo and Liu2016).

In 2015 the Chinese government introduced the GP concept to limited areas, such as Shanghai (Jing et al., Reference Jing, Shu, Sun, Chiu, Lou and Xie2015), Chongqing (Chen et al., Reference Chen, Xu, Yang, Tan and Zhang2015) and Guangdong (Kuang et al., Reference Kuang, Liang, Zhao, Wang, Liang and Shi2015), to study the impact. A great deal of positive evidence has been reported, especially enhanced and timely medical services and a growing satisfaction with the medical experience. These promising outcomes accelerate the progress of nationwide implementation. Nevertheless, the selected experimental areas are mainly well-developed cities where people enjoy a higher level of social welfare, including education and medical care, than the average person in China.

Situations will be different, or even more complicated, when GP services are extended to the whole nation. Admittedly, it is necessary to introduce the GP to establish and strengthen the gatekeeping primary care in China, but it might turn out to be a problem if the Chinese healthcare system or even the entire society is unprepared. So it is important for the central government to secure a sound legal environment for GP services before nationwide implementation.

Assessing internal structure: current effective laws and regulations

Theoretical studies involving legal norms and GPs mainly concentrate on altering individual behaviours in the healthcare sector, both from the perspectives of controlling the over-prescription of drugs and medical malpractice, and dealing with violence against GPs (Sage et al., Reference Sage, Hastings and Berenson1994; Allen, Reference Allen2000; Hoffmann and Tarzian, Reference Hoffmann and Tarzian2003; Roberts et al., Reference Roberts, Hsiao and Berman2004; Hesketh et al., Reference Hesketh, Wu, Mao and Ma2012; Durand et al., Reference Durand, Moulton, Cockle, Mann and Elwyn2015; Xing et al., Reference Xing, Jiao, Ma, Qiao, Hao, Li, Gao, Sun, Kang, Liang and Wu2015).

Specifically, Chinese lawmakers have enacted the Tort Law (2009) to control medical malpractice, the Law on Practising Doctors (Revision, 2009) to deter and punish physician misbehaviours, and Amendment (IX, 2015) to the Criminal Law to punish perpetrators of physical violence against medical professionals. Table 2 outlines provisions contained in a select group of relevant laws and regulations covering the important areas of medical practice. It is easy to see that the majority of current legal norms have been effective since 2009. This is partially because a deep reform of the Chinese healthcare system was initiated in that year. In truth, legal norms have served mostly as tools for achieving certain political goals, rather than as a means of independent oversight to monitor and assess the performance of government agencies. This practice has placed the authority of legal norms at risk. Thus, the proper role of legal norms in improving the Chinese healthcare system needs to be re-affirmed deliberately.

Table 2 Effective legal norms concerning important areas of medical practiceFootnote ^a

^a English translation of laws and regulations is from pkulaw.cn http://en.pkulaw.cn/. Accessed 7 April 2017.

^b The 2013 National People’s Congress announced the establishment of the National Health and Family Planning agency to replace the former Ministry of Health and National Population and Family Planning Commission.

The fragmented legal norms may also be incompatible with the concept of GP services, since they were issued to deal with the problems generated by the hospital-based delivery system. Put differently, the current version of Chinese healthcare was designed with less attention to support integrated care, and there was hardly any attempt to consolidate the fragmented legal norms. So the fragmentation of legal norms needs to be taken seriously before any substantial steps are taken to implement GP services nationwide.

The current legislative method also has a deficiency. Regulations are more likely to be issued in the domain where bad behaviour causes the worst consequences (Roberts et al., Reference Roberts, Hsiao and Berman2004). Consequently, certain domains are overwhelmed by overlapping legal norms, while some domains are regulated either implicitly or far from adequately. For instance, informed consent, which is the essential element of patient rights, is merely protected by Article 26 of the Law on Practising Doctors, which stipulates: ‘Doctors shall tell the patients or their family members the patients’ condition truthfully. However, care shall be taken to avoid an adverse impact on the patient. Doctors shall get the approval from the hospital and the consent of the patient or family members before conducting clinical treatment on an experimental basis’ (Article 26, Law on Practicing Doctors, 2009 Revision). Thus, doctors have a ‘notification responsibility’ (Meng et al., Reference Meng, Yang, Chen, Sun and Liu2015: 62) to honestly provide medical information (eg, illness conditions, risks and treatment options) to patients and their families, but there is no explicit regulation on the extent and scope of discourse. Since no consensus has been reached regarding whether informed consent is a legal mandate or merely an ethical requirement, this implicit way of regulation seems to be fine for the current Chinese healthcare system (Rao, Reference Rao2008). Nevertheless, it would no longer be sufficient after transition to the GP system, since the good performance of GPs relies on a higher level of mutual trust and a closer, contractual doctor–patient relationship. In the new context, informed consent should be affirmed as a mandatory duty, and should be regulated strictly in terms of both extent and scope. Therefore, optimisation of the legislative method to cover all related domains needs to be addressed in order to regulate GP services effectively.

In summary, the regulatory sector of the Chinese healthcare system is unprepared in terms of its internal legal structure. Before the nationwide implementation of GP services, relevant government agencies need to make a joint effort to alter the problematic role of legal norms, to consolidate fragmented legal norms, and to optimise the legislative method.

Exploring external factors: cultural attitudes, government capacity and interest groups

Which external factors are impediments to the regulatory changes required for reform of the Chinese healthcare system? According to the ‘five-control knob’ framework (Roberts et al., Reference Roberts, Hsiao and Berman2004), there are three external factors influencing reform efforts in the regulatory sector: ‘cultural attitudes, government capacity and political support’. In our analysis, we have replaced the third benchmark with ‘interest groups’. Although Roberts et al. (Reference Roberts, Hsiao and Berman2004: 255) have briefly discussed the organised interest groups and their potential influence on the reform efforts, their major concern is not to identify those interest groups, but to use them as a juncture to address the importance of strengthening political support (ie, political skills, regulatory process and effective implementation) in regulation design. However, the aim of this section is to identify the external factors that actually impede the reform of China’s primary care. Thus, we use ‘interest groups’ instead of ‘political support’ with a conviction that the solid alliance that has been formulated between pharmaceutical companies and major hospitals deserves equal attention.

External factors will be explored by answering questions. What is the cultural attitude, generally and specifically, about using regulations to drive the performance of the Chinese healthcare system? Do the relevant government agencies have adequate capacity to assure the enforcement of regulations? Does the regulatory sector have enough support to ensure the effectiveness of the GP system?

Internal reform: enactment of a specific law

Legal norms should be issued and organised to shield people from the potential adverse effects of the GP system. Apparently the current effective legal norms concerning practising doctors are incompatible with the proposed GP services. A review of the laws and regulations, as listed in Table 2, indicates a great need to eliminate fragmentation to prevent conflict between overlapping legal norms.

In the future, steps can be taken to revise the Law on Practising Doctors by amending and inserting articles in line with the requirements for the administration of GP services. Take licensing and accreditation as simple examples. Medical institutions in China, whether focusing on medical treatment or disease prevention, have an affirmative responsibility to measure the performance of all doctors who have registered in their institutions, not only in terms of reporting malpractice and medical accidents (Article 16), but also in terms of providing training and continued education (Article 35). With regard to the proposed GP services, who should take up those responsibilities? In accordance with the National Health and Family Planning Commission of the P. R. China (2016), the GP is an identifiable person with primary responsibility for his or her medical group (Jing et al., Reference Jing, Shu, Sun, Chiu, Lou and Xie2015). Put differently, the GP has to self-report malpractice and medical accidents, which seems difficult or even impossible to realise. Such regulations should therefore be revised with a thorough consideration of feasibility.

Furthermore, the GP system adopts a ‘1+1+1’ contract model, which means that patients are encouraged to sign the contract with one GP group plus one secondary hospital plus one tertiary hospital. This contractual character of the doctor–patient relationship under the GP system deserves special attention. It implies that people living in China need to be empowered and activated in order to choose the best contract. Once again, regulators have to be cautious when adopting new concepts. If GP services are governed by contractual considerations, then regulations have to deal with the unequal positions of GPs and their patients. In this respect, regulations should be formulated with special attention devoted to creating a supportive legal environment, such as securing patients’ right to information, providing an effective complaint process, and other empowering measures [eg, ‘building health literacy, improving self-management skills, cultivating shared decision-making and creating a supportive environment’ (The World Bank Group et al., Reference Wiley2016: 52)].

Moreover, does the GP have the right to choose patients when the contractual relationship implies an exclusive relationship? According to Article 24 of the Law on Practising Doctors, doctors have an affirmative responsibility to take care of patients under emergency situations. Certainly, any emergency case should be excluded from contractual conditions due to humanitarian values. How about other cases? If the GP is entitled to select patients, is there any difference between commercial insurance companies and the GP? Will the rights of doctors or insurance companies limit the accessibility of healthcare for patients who suffer from severe chronic diseases? Since the law will affect everyone, Chinese lawmakers need to consider this issue carefully.

Last but not least, considering the fact that there exists a wide disparity between urban and rural areas in primary care in China (Shi, Reference Shi1993; Liu et al., Reference Liu, Hsiao and Eggleston1999; Zhang et al., Reference Yip and Hsiao2016), future legislation should pay special attention to assisting the implementation of GP services in the rural areas of China where people are more likely to suffer from lack of medication and qualified personnel in healthcare. However, this raises many other questions, such as should legislation interfere in the career choices of medical graduates for the sake of dealing with the shortage of healthcare personnel in rural China? Questions like this are crucial for future legislation and thus need to be considered fully during legislative design.

External reform: creation of an independent regulatory oversight body

In general, Chinese healthcare reform has been managed in a multi-leadership style. The government agencies in charge are the National Health and Family Planning Commission, the Ministry of Finance, the National Development and Reform Commission, and the Ministry of Human Resources and Social Security. Each government agency represents its own political constituency, which results in weak interagency communication and collaboration. Reform plans developed in this multi-leadership style are highly likely to fall short in accountability provisions for each sector, and to contain contradictory arrangements. Although a typical example of multi-sector cooperation exists in China, the Patriotic Health Campaign (Meng et al., Reference Meng, Yang, Chen, Sun and Liu2015: 15), this cross-sector coordination mainly focuses on protecting and promoting public health services instead of the entire primary care. Given these drawbacks, together with the substantial discretion of local governments and the physician self-reporting dilemma, the enforcement process performs poorly in practice. Successful implementation of the GP system calls for greater attention to the regulatory body. Creation of an independent regulatory oversight body may be a feasible strategy to pave the way for nationwide implementation.

There are two essential elements of the proposed independent regulatory oversight body. One refers to the involvement of professionals with multi-disciplinary backgrounds. Since healthcare reforms depend on consistent systematic efforts, the proposed body should recruit physicians who are able to provide clinical insight due to their front-line role in the healthcare system, economists who can provide input on sustainability and effectiveness, legal professionals who can draft laws and regulations to prevent misbehaviour and shield people from the adverse effects of reform, ethicists who can provide guidance on humanitarian performance, and professionals from social media who can cultivate cultural attitudes by educating people to be responsible and rational beneficiaries of the reform.

Procedural justice is another concern. Formulating an independent regulatory oversight body should not be regarded as an attempt to replace any effective government agency. On the contrary, it should function independently as a bridge to mitigate the conflicts resulting from the multi-leadership style. In addition, the oversight body should not only serve as a surveillance tool, but should also provide an open process for mediating medical disputes.