The Role of Integrated Primary Health Care in China

By Hao Yi Tan

Overview of China’s Healthcare System

In recent times, China's demographic landscape has undergone notable changes. Historically recognized as the world's most populous nation, China relinquished this position to India in 2023 (1). China's population is estimated at around 1.4 billion individuals as of 2024, with a significant decline in birth rates in recent years. In 2016, birth rates fell below replacement level, indicating a demographic shift where the number of births no longer replaces the deceased population. Furthermore, there is an emerging challenge of an aging population. With fewer young individuals entering the workforce and a growing number of retirees, China faces potential strains on economic growth and social welfare systems. This interplay of factors highlights the intricate relationship between policy interventions, demographic shifts, and their broader socio-economic implications within China's evolving population narrative. Furthermore, China’s rapidly ageing population also means that it’s healthcare system has to deal with an a tidal wave of chronic diseases and aged-care related issues.

Current Issues with China’s Healthcare System

China's healthcare system has undergone significant reform efforts in recent years, with the aim of expanding insurance coverage and enhancing service quality. Notably, China has instituted a social health insurance system which covers 96% of the population (2). However, several key challenges persist, indicating areas for further improvement and attention.

1. Urban-Rural Divide: Like India, China struggles with providing health services across their vast geography, particularly in the rural areas. The concentration of high-quality hospitals and skilled medical professionals in urban areas has left rural communities underserved, most if few to no PHC providers and no specialists (3). Furthermore, the education and qualification amongst PHC professionals in China are considerably low, with a large number of unlicensed practitioners (4). This has resulted in disparities in access to quality healthcare, particularly for individuals who face barriers related to affordability and geographical distance.

2. Hospital-Centric Nature of the Healthcare System: This reliance on hospitals in China’s healthcare system has led to issues such as overcrowding and potentially unnecessary admissions for minor medical concerns. China’s PHC providers do little gatekeeping for secondary and tertiary healthcare services. They are often not the first point of contact for patients, nor do they coordinate with specialists for care of patients, resulting in a fragmented system (5).

3. Wastage and Inefficiencies: Despite efforts to control costs, inefficiencies and instances of wastage persist. This takes the form of unnecessary diagnostics and treatments, resulting from a fee-for-service (FFS) payment structure and ability to charge markups on drugs that incentivizes such behavior (6). Furthermore, there are reports of widespread falsification of documents and false insurance claims (7).

4. Aging Population: China's aging population as a whole presents unique challenges for the healthcare system (8). Firstly, non-communicable diseases (NCDs) such as hypertension are underdiagnosed and undertreated by PHC providers (4). Secondly, the prevalence of NCDs are increasing with a growing proportion of the population being elderly. Therefore, there is a need to tailor healthcare services to meet their specific needs and ensure adequate support for long-term care. In particular, many young individuals move to the city for work opportunities, leaving the elderly behind in rural areas where healthcare is the least accessible.

The Importance of PHC-based Integrated Delivery Systems in China’s Aging Population

China, like India, is confronted with the task of catering to a sizable rural population in need of healthcare services. The nation's heavy reliance on hospital-centered care has led to challenges such as overcrowding and unnecessary hospital admissions, with significant underutilization of lower level care (9). To address these issues effectively, there is a pressing need to strengthen primary care services capable of serving patients at the community level. This approach can lead to lower-cost treatments and more appropriate care, thereby reducing healthcare spending for both individuals and the overall healthcare system.

Additionally, China's aging population requires improved care coordination, particularly given the evolving disease profile marked by an increasing prevalence of chronic conditions such as hypertension, diabetes, hyperlipidemia, and mental health disorders. At the same time, this population will need quality aged care and palliative care. These care needs necessitate ongoing management, either through interactions with primary care providers for prescriptions and checkups or, in some instances, referrals to higher-level care facilities like secondary and tertiary care centers. Consequently, establishing a robust IDS, and one that is rooted in primary healthcare becomes crucial to ensure seamless continuity of care, prevent patients from falling through the cracks, avoid duplicative tests and treatments, and facilitate easy access to patient medical history.

The failure to develop a robust PHC-based IDS could potentially strain China's healthcare system in the coming decade due to the increasing burden of chronic diseases. Thus, investing in and strengthening primary healthcare services is critical for China's healthcare system to effectively manage the challenges posed by the growing prevalence of chronic conditions and aging demographics.

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References

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8. Bao J, Zhou L, Liu G, et al. Current state of care for the elderly in China in the context of an aging population. Bioscience trends 2022; 16(2): 107-18.

9. Liu Y, Kong Q, Yuan S, Van de Klundert J. Factors influencing the choice of health system access level in China: a systematic review. The Lancet 2018; 392: S39.