The researchers found that countries with a higher density of skilled health workers could expect to have better health outcomes across all six measures of health outcomes. Unsurprisingly, high-income countries generally enjoy a high density of skilled health workers and world-leading health outcomes, whereas low-income countries suffer from a shortage of health workers and poor health outcomes. A higher density of skilled health workers was also significantly correlated with a lower level of COVID-19 excess deaths per 100,000 people, highlighting the importance of the health workforce under the pandemic.

A Cause and Effect of Socioeconomic and Health-System Developments

The cross-country results confirm the importance of the health workforce in affecting multiple health outcomes. “Therefore, investment in health workforce should be an integral part of the strategies to improve health outcomes and achieve health-related SDGs for every country, especially for low- and lower-middle-income countries,” write Eggleston and Liu. The vast majority of these countries (about 80%) are tremendously off track to meet the health-related SDGs by 2030.

From a global perspective, the data underscores the wide disparities in health outcomes between different countries, especially between those most and least advantaged (e.g., healthy life expectancy at birth of 44.9 years in the Central African Republic compared with 76.2 years in Singapore).

It is difficult, however, to improve disparities in health outcomes between countries in different income categories by improving the density of the health workforce alone. The reason is that socioeconomic factors, as the data confirms, are critical determinants of health outcomes. For example, higher health expenditure per capita and the poverty headcount ratio have significant associations with all six health outcomes, while female education is interrelated with broader social determinants of health.

Thus, the relationship between the health workforce and health outcomes is the cause and effect of broader socioeconomic and health-system developments. “A strong health workforce contributes to better health outcomes and is itself a manifestation of a country’s previous investments that reduced poverty, improved health outcomes, and laid the foundation for a robust health system,” Eggleston and Liu explain.

Investment in the health workforce is an urgent task, the researchers conclude. It should be an integral part of strategies to achieve health-related SDGs, and these strategies, in turn, should include means to achieving complementary non-health SDGs related to poverty alleviation and expansion of female education.

The results show that the pandemic’s broad social and economic impact has adversely affected population health well beyond those directly suffering from COVID-19. Study participants with chronic conditions faced significant challenges in managing their symptoms during the pandemic. They experienced a loss of income and difficulties in accessing healthcare or medications, with the resulting delayed and foregone care leading to uncertain longer-term effects. For a nontrivial portion of participants, these factors are associated with the worsening of diabetes symptoms. The threat is twofold among people living in rural populations with limited access, availability, and affordability of healthcare services.

A Global Health Priority

The unintended adverse consequences of the COVID-19 pandemic on chronic disease care may also further aggravate inequality in health outcomes. “If the trend continues and no immediate actions are taken to mitigate pandemic impacts,” Eggleston and her colleagues caution, then “the Asia-Pacific region will struggle to achieve the 2030 Sustainable Development Goal (SDG) target 3.4 to reduce premature mortality from non-communicable diseases by a third relative to 2015 levels and to promote mental health and wellbeing.”

Addressing the pandemic’s unintended negative social and economic impacts on chronic disease care is a global health priority, determine the researchers. They propose several measures to help provide timely care for people with chronic conditions in resource-constrained settings. These include implementing innovations in healthcare delivery models to improve the adoption of healthy lifestyle changes and self-management of chronic disease and mild COVID-19 symptoms, increasing investment in interventions to provide social and economic support to disadvantaged populations, and strengthening primary healthcare infrastructure and support of healthcare providers.

The study was supported in part by funding from Shorenstein APARC’s faculty research award, Stanford King Center for Global Development, and a seed grant from the Stanford Center for Asian Health Research and Education.

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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.

“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.

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.

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.