Strengthening the Frontline: How Primary Health Care Improves Net Value in Chronic Disease Management

Empirical evidence by Karen Eggleston and colleagues suggests that better primary health care management of chronic disease in rural China can reduce spending while contributing to better health.
 A woman at a desk in a village medical clinic in China. A village medical clinic in China. Marie Anna Lee, University of the Pacific, CC BY-NC-ND

While the coronavirus pandemic has captured the world’s attention, non-communicable chronic diseases (NCDs) such as hypertension, heart diseases, and diabetes continue to be the leading cause of mortality worldwide, accounting for about two-thirds of deaths globally. Their financial and social burden is also immense, as individuals with chronic diseases face high medical spending, limited ability to work, and financial insecurity. Primary health care (PHC) is a crucial avenue for managing and preventing chronic diseases, yet many health systems, especially in low- and middle-income countries (LMICs), lack robust primary health care settings. How can policymakers improve PHC to reduce illness and death from chronic diseases?

There is little rigorous evidence from LMICs about the effectiveness of programs seeking to improve the capacity of PHC for controlling chronic disease. Now a new study, published by the Journal of Health Economics, helps fill in this gap. It offers empirical evidence on China’s efforts to promote PHC management, showing that better PHC management of chronic diseases in rural areas can reduce spending while contributing to better health. We sat down with APARC’s Asia Health Policy Program Director Karen Eggleston, one of the study co-authors, to discuss the research and its implications beyond China. Watch:

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Challenges for Primary Health Care Services

China, a large and rapidly developing middle-income country with a hospital-based service delivery system for its aging population, makes a suitable case study of efforts to promote PHC management. Over the past several decades, PHC use in China has significantly decreased relative to hospital-based care. This trend is a natural consequence of the country’s unprecedented increases in living standards and improvements in financial risk protection, which increase patients’ demand for quality care and spur self-referral to providers with higher-perceived quality like hospital outpatient departments.

The performance differences between PHC and hospital-based care are especially stark in China’s rural areas, where management of chronic diseases relies heavily on grassroots physicians, who have limited medical education and training. That is why Eggleston and her colleagues set out to provide new empirical evidence about the effectiveness of a program that promotes PHC management of hypertension and diabetes for rural Chinese. Part of the National Basic Public Health Service Program for rural Chinese, it financially rewards PHC grassroots physicians for managing residents with chronic diseases.

Collaborative Research in the Era of Great Power Competition

Eggleston’s co-authors include her colleagues at the Zhejiang Provincial Center for Disease Control and Prevention (Zhejiang CDC). Their study is the culmination of Eggleston’s multiyear collaborative research project with the Zhejiang CDC team, "Addressing Health Disparities in China," which looks to Tongxiang county in Zhejiang as a case study of China's responses to healthcare inequalities and population aging challenges in rural and urban areas. The project also involved two Stanford doctoral students who worked with Eggleston.

The team worked together to develop the quantitative analysis even during a time of sometimes-tense bilateral relations. “We found it very important to be able to communicate directly and collaborate on an important question not only for rural China but for many other parts of the world,” says Eggleston.
Karen Eggleston speaking to staff at Zhejiang Provincial CDC, China
Eggleston with her colleagues at the Zhejiang CDC during a field visit in 2018.

“This kind of collaboration, where we utilize the data that's available to answer an important question while respecting the privacy of the individuals and hopefully delivering benefits to them through more effective or affordable programs in the future perhaps is a promising model for researchers here and elsewhere to undertake,” she notes.

Disentangling the Effect of Primary Health Care Management

To study the program’s effectiveness, the researchers assembled a unique dataset linking individual-level administrative and health information between 2011 and 2015 for rural Chinese diagnosed with hypertension or diabetes in Tongxiang, a mostly rural county of Zhejiang province in southeast China. Collected by the Tongxiang CDC and Zhejiang CDC, the compiled database links basic demographic information, health insurance claims, PHC service logs, and health check-up records — four sets of data that are rarely linked and analyzed in combination in China healthcare research.

Focusing on neighboring border-straddling villages allows us to use only variation in PHC management within pairs of neighboring villages to identify the effect.
Karen Eggleston

Targeting the program’s effects on healthcare utilization, spending, and health outcomes, Eggleston and her colleagues compare residents in neighboring villages that straddle township boundaries. These residents are similar in their individual and environmental characteristics that shape health care use but are subject to different PHC management practices. This “border sampling” allows the researchers to disentangle the effects of PHC management from other underlying spatial differences that impact health care utilization. For each township, the researchers use a management intensity index that reflects the cumulative efforts of PHC physicians to screen their communities and keep patients within the PHC management programs for controlling hypertension and diabetes. Each township’s experience with PHC management over the 5-year study period is thus a case study for rural China.

Net Value in Chronic Disease Management

The results are encouraging for China's investment in primary care management of chronic diseases. Eggleston and her colleagues find that patients residing in a village within a township with more intensive PHC management had a relative increase in PHC visits, fewer specialist visits, fewer hospital admissions, and lower spending compared to neighbors with less intensive management. They also tend to have better medication adherence and better health outcomes as measured by blood pressure control.

If we can gradually scale up these kinds of effective programs at primary care then we can build more resilient, cost-effective, affordable health care systems for populations in many different settings.
Karen Eggleston

The results suggest that PHC chronic disease management in rural China improves net value in multiple ways — increasing PHC utilization, reducing avoidable hospitalizations, decreasing medical spending, and improving intermediate- and long-run health outcomes — all while leveraging existing resources rather than restricting care.

The findings also help inform investments in primary health care in LMICs. They highlight the latent potential of frontline healthcare workers in such settings to be more productive and show that financially rewarding these grassroots workers for managing residents with chronic diseases helps improve health outcomes. Moreover, they offer empirical evidence that supports the effectiveness of chronic disease management programs as part of broader regional initiatives to address population health.

Read the study by Eggleston et al

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