Implementation Strategies for Primary Health Care in China and India
By Hao Yi Tan
Overview
Three common strategies that have been found to be crucial to the formation of successful integrated delivery systems include the following:
Vertical Integration and Payment Alignment: Firstly, there's a consistent emphasis on vertical integration within the system, aligning primary, secondary, and tertiary care under the same organizational structure, clinical workflows, and health information exchanges. Importantly, provider payment methods (especially at the PHC level) are considered in order to align incentives of providers and the health system itself.
Leveraging Digital Health and Health IT: Secondly, digital health and health IT integration has been shown play a crucial role, especially in integrating EHRs to ensure seamless access to patient information across all levels of care within the health system. Furthermore, usage of telehealth tools will significantly improve the capabilities of PHC providers.
Primary Healthcare Reform and Expansion: Lastly, there is strong realization in both systems that there is a need to base their IDS on primary and preventive care, rather than hospital centric curative care. There is a focus on primary care, as well as deliberate effort in integrating primary care with chronic disease management, whether it's mental health integration as seen in Intermountain's case or the inclusion of chronic disease ancillary screening services and management in Singapore's approach.
These broad lessons of building effective IDSs can be adopted by developing nations to reform their healthcare systems. Though they cannot directly copy the actions of the Singapore government or Intermountain Health’s leadership, the common themes shed light on areas that developing countries can focus on in shaping their health systems to become capable IDSs. We present the recommendations for India and China below.
Recommendation 1: Vertical Integration and Payment Alignment
India
Vertical integration of healthcare entities at the state level can especially help to tackle issues faced in rural India. Intermountain provides care in more remote areas by integrating primary care practices in these communities into their larger Intermountain system. They are paid for the services they provide, but also are able to tap into Intermountain’s larger network of hospitals for additional resources. If India is able to integrate the various healthcare entities within each state and emphasize the manpower capacity building, the smaller and more poorly resourced practices can tap into the resources and expertise of the larger hospital systems to expand their capacity. For example, non-physician PHC providers can use telehealth to consult more qualified professionals such as physicians or specialists for cases they are unsure of, thus greatly expanding their treatment capacity without much costs. This can also help with manpower shortages, and the quality control of medical practice by establishing clinical protocols and enforcement. Furthermore, large hospital systems are better able to establish strong supply chains of medication and equipment, hopefully avoiding issues of understocking altogether.
Furthermore, India can establish performance accountability systems that provide bonuses for good performance, and enforce systematic quality improvement initiatives. Furthermore, they can incentivize good quality care by establishing pay-for-completion at the PHC level, such as completing chronic disease screening or vaccinations while in primary care visits. These measures need proper enforcement by government authorities so that healthcare workers are less able to cheat the system (such as by having a dual public-private practice).
China
China like Singapore, can depend on vertical integration to provide much needed chronic care and aged care to the rapidly aging population. In both cities and rural areas, vertical integration of care can focus on hospital systems establishing standardized clinical workflows and EHRs between acute hospitals, sub-acute hospitals and PHC entities. Doing this will enable continuity of care, which is especially important because chronic conditions such as diabetes and hypertension require care coordination across health institutions and even after patients return home. Having well established protocols for step-down or escalation of care as well as EHR integration for interoperable flow of patient data in a vertically integrated province or county-wide level will be extremely beneficial. In particular, it will help to decrease duplication of tests or treatments, prevent avoidable medical errors, and ensure that patients are receiving the appropriate level of care. Rural PHC entities integrated into the larger health system can similarly use telehealth to consult more qualified individuals for more complex cases, improving care for patients without needing to physically transfer them to larger hospitals.
Furthermore, one of the ways the Chinese health system can combat high healthcare wastage due to over-prescription and unnecessary testing is to reform their PHC payment system from a FFS arrangement to a capitation model, a move similar to the HealthierSG movement in Singapore. The Chinese government can fund PHC organizations by the number of patients that they serve, thus financially incentivizing them to engage in preventive medicine and community health efforts that are low-cost but high value in order to maximize their own profits.
Summary
Vertical integration incurs initial costs, but eventually yields considerable long-term benefits. They offer potential cost savings and improved patient outcomes, notably through better coordination, care continuity, and reduced errors. This enhances healthcare service quality, optimizes resource utilization (such as procurement support and staff training), and cuts unnecessary expenditures.
Recommendation 2: Leveraging Digital Health and Health IT
Health IT and digital health are enablers of healthcare integration. Both India and China can better integrate their health systems by pushing for more advanced and interoperable health information exchange tools that allows for universal access to patient access. Such an electronic system, implemented in parallel with vertical integration of state or county health systems will help with coordination of care across space and time, ensuring better continuity of care and reducing duplication. If successful, aggregated health data can be studied closely in order to identify gaps in care and areas of waste in the system, much in way that Intermountain Health implemented their RPC program.
India
India should focus building a patient portal similar to that of Intermountain’s or Singapore’s Healthhub, incentivizing patients to utilize these smartphone applications or web portals to manage their health. Providers can be incentivized to be “data contributors” to the patient records, reporting test results, patient notes and medication histories. This patient-centric strategy (as opposed to a government owned national EHR like Singapore’s) may serve India better because of the heterogenous mix of public and private healthcare institutions serving the population. Furthermore, smartphone adoption in India is increasing as the country continues to develop (1). If Indian citizens utilize such a patient portal at scale, both public and private providers can utilize the portal to glean important information about patients they see, even if the patient has seen a myriad of different providers for healthcare.
China
China on the other hand, can focus on developing a national EHR modelled after Singapore’s, since the government is better able to exercise regulatory control over the health system and compel providers to contribute a central database of patient records. Using this, China can work towards a “one patient, one record” model that Singapore uses, and thus vastly increase interoperability of medical records. China can also consider setting up country-wide statutory bodies similar to Singapore’s Synapxe or Agency of Integrated Care (AIC) which are tasked with building cohesive integrated technology systems.
Summary
In the post-pandemic era, many health systems worldwide have increasingly turned to telehealth solutions with notable effectiveness. The implementation of technology supporting telehealth capabilities is especially advantageous for rural populations in various countries, addressing the challenges of deploying healthcare professionals to remote areas. By outfitting rural health facilities with essential infrastructure such as internet connectivity, computers, cameras, and appropriately trained staff, telehealth consultations with doctors become feasible regardless of their physical location. This approach not only mitigates the necessity for physicians to physically travel to rural regions but also optimizes their time and resources, enabling them to serve multiple locations efficiently. Through effective integration of PHC with secondary and tertiary hospitals, telehealth can enhance medical capabilities, following models like Intermountain Health's strategy. Teleconsultations bridge geographical gaps for patients in remote areas, offering access to specialists without extensive travel, while fostering collaboration between primary care providers and specialists for timely and effective care escalation. Additionally, telehealth facilitates knowledge sharing among healthcare professionals, empowering PHC providers to manage a broader range of conditions and alleviating pressure on specialist hospitals. Furthermore, establishing medication delivery mechanisms post teleconsultations enhances patient convenience and adherence to treatment plans, particularly for chronic conditions requiring continuous medication management.
Recommendation 3: Primary Healthcare Reform
Both Singapore and Intermountain Health recognize that in order to build a sustainable and quality IDS, it needs to be grounded upon strong PHC. The problems faced by India and China’s population will require a solid foundation of PHC provision to tackle, especially as they tackle the dual burden of NCDs and CDs.
Integrate Primary Care with Public Health Functions
In both India and China, the health system should integrate the PHC functions with public health functions, especially outside of major cities. For example, PHC providers can be funded to take on the role of vaccination drives, maternal and child health education, and health promotion for chronic disease prevention (e.g. nutrition education for diabetes and hypertension), especially in the rural setting. India is further ahead in this respect, where public health workers and conduct public health and nutrition campaigns at the village level on a consistent basis. However, they are limited in scope and healthcare worker shortage is also a recurrent issue. Currently, much of PHC provider work in China is limited to acute care. Both India and China can consider integrating PHC functions with public health functions and incentivize them to engage in preventive care while providing clinical care. This would lead to improved management and thus better long term outcomes for patients.
PHC Providers Should Take on the Role of Care Coordination
Both India and China face a rising tide of chronic disease. A significant part of PHC reform for both countries then should be to take on the role of care coordination, especially for individuals with multiple chronic diseases. Proper care coordination by PHC providers has been well established at improving health outcomes and reducing disparities (2). PHC providers in both countries can take on that role with enough training, and nudge the population towards better self-management of their health conditions and prevention via lifestyle changes. Especially for rural PHC providers, they are well placed to perform the care coordination role as they tend to be located in the same geographic areas as those they serve.
Expanding PHC Functions to Manage Complex Chronic Diseases including Mental Health
Reimagining and integrating primary care services with chronic disease management is likely to be a key strategy in improving healthcare delivery, particularly in large countries like India and China. Aside from increasing chronic disease prevalence, there is also a rise of mental illness (3,4). Like Intermountain Health, both countries can consider expanding the function of PHC providers to include mental health treatments by training and incorporating mental health workers into PHC teams. Like Singapore’s PCNs, PHC entities can form networks to pool resources, sharing administrative resources and have visiting teams of healthcare workers to conduct screening and other services that otherwise would not be available to each individual PHC provider.
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