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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.

Modeling Health Outcomes Among East Asian Populations

The chronic progression to diabetes-related complications is apt for computer simulation modeling due to the long-term nature of health outcomes and the time lag for interventions to impact patient outcomes. It is problematic, however, to estimate the impacts of health interventions on East Asian populations with diabetes using existing models, which were developed and validated in European and North American populations with different epidemiology and outcomes.

To fill in this gap, Eggleston and her colleagues set out to develop and validate an outcomes model for the progression of diabetes and related complications in Chinese populations. They compared this new model, called the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME), to two widely used existing models developed and validated in the United Kingdom (known as the United Kingdom Prospective Diabetes Study Outcomes Model 2, or UKPDS-OM2) and in the United States/Canada (called Risk Equations for Complications of type 2 Diabetes, or RECODe). Despite the continuum of risk across the spectrum of risk factor values, these two existing models ignore the progression from prediabetes to diabetes.

The CHIME integrates prediabetes and diabetes into a comprehensive model comprising 13 outcomes. These include mortality, micro- and macrovascular complications, and the development of diabetes. The researchers developed the CHIME simulation model using data from a population-based cohort of 97,628 participants in Hong Kong with type 2 diabetes (43.5%) or prediabetes (56.5%) from 2006 to 2017. Known as the Hong Kong Clinical Management System (CMS), this cohort makes one of the largest Chinese electronic health informatics systems with detailed clinical records. 

The next step was to externally validate the CHIME model against individual-level data from the China Health and Retirement Longitudinal Study (CHARLS) cohort (2011-2018), a nationally representative longitudinal cohort of middle-aged and elderly Chinese residents age 45 and older. The researchers validated the CHIME model against six outcomes measures recorded in the CHARLS data and an additional 80 endpoints from nine published trials of diabetes patients using simulated cohorts of 100,000 individuals.

Towards Reducing the Disease Burden of Diabetes

The researchers found that the CHIME model outperformed the widely used UKPDS-OM2 and RECODe models on the data used, meaning that the validation of the CHIME model was more accurate for trials with mainly Asian participants than trials with mostly non-Asian participants. The results indicate that the CHIME model is a validated tool for predicting the progression of diabetes and its outcomes, particularly among Chinese and East Asian populations, for which the existing models have been unsuitable.

With the new model, clinicians and health economists can evaluate population health status for prediabetes and diabetes using routinely recorded data and therapies related to the long-term management of diabetes. In particular, the CHIME outcomes model enables them to assess patients' quality of life and measure cost per quality-adjusted life-years over the long-time horizon of chronic disease conditions. The new model thus supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes, address micro- and macrovascular complications associated with these conditions, and improve life expectancy.

We sat down with Jain to discuss her work and recent research into the ways the COVID-19 pandemic has affected the efficacy of India’s healthcare services for people living with chronic, non-communicable diseases. Listen to the full conversation above or via our Soundcloud channel.

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Jain’s research focuses on the role of the private sector in health systems, frictions in health care markets, the extent to which public health policies serve the needs of target populations, and health policy design in lower-income countries. In particular, she studies India's health care system, probing into data sets and administrative records to identify the factors that contribute to poor health outcomes and determine what interventions increase the effectiveness of public health insurance.

In the case of India, the private healthcare sector is highly fragmented and made up of a collage of small and independently-run hospitals and service providers with varying levels of oversight and administrative regulation. Gathering data on patient costs, insurance use, and benefit allocation for different cohorts of people using private healthcare in the world's second-most populous nation is a central pillar in Jain's efforts to better understand and document how health systems are used and how they can be improved to better serve vulnerable populations.

COVID-19 Lockdown Impacts on Non-COVID Health Care and Outcomes

For Jain, the ongoing effects of the COVID-19 pandemic have re-emphasized the crucial role that a well-functioning public, government-backed health system plays in providing care to citizens during times when the private sector experiences sudden and severe disruptions. Working in collaboration with Pascaline Dupas, the faculty director at the Stanford King Center on Global Development and a senior fellow at the Stanford Institute for Economic Policy Research, Jain has documented the adverse effects of COVID-19 on accessibility to health services for patients needing treatment for chronic, non-communicable diseases.("The Effects of India’s Covid-19 Lockdown on Critical Non-Covid Health Care and Outcomes: Evidence From a Retrospective Cohort Analysis of Dialysis Patients"

Jain's and Dupas' recent working paper (published in AHPP's Working Paper Series) shows that the abrupt, severe lockdown instituted by the Indian government as a preventive measure against the spread of the coronavirus had widespread impacts on individuals' ability to receive care for non-COVID-related healthcare needs such as dialysis. Their findings indicate that, among patients needing dialysis, the death rate between April and July 2020 was 25 percent higher than the death rate for a comparable cohort in the same months in 2019.

This increase in mortality is directly related to disruptions to critical health service delivery and accessibility caused by the lockdown measures. Sixty-three percent of those surveyed by Jain and Dupas reported experiencing disruptions to their care, with travel barriers and hospital closures or refusals cited as the most common causes. As a cohort, vulnerable populations were affected most by both the lockdown and ensuing disruptions to healthcare access.

Discrepancies like this between how a health system performs on paper and what happens in real-world practice is something Jain has a deeper appreciation for in light of the pandemic. “There were many policy prescriptions about how to respond to the lockdown, but what was done in India was a poorly conceived political response,” she cautions. “That’s something we who work on health policy need to keep in mind and contend with: What is the role of the political system, what is the role of the health system, and how does our research interact with all of that?”

Looking ahead, Radhika intends to continue researching and writing recommendations on how to make health systems viable and usable for all populations, including the most vulnerable. In particular, she is interested in investigating strategies to close engagement gaps and accessibility challenges women in India experience in utilizing healthcare services. She will continue working at APARC as a postdoctoral fellow with the Asia Health Policy Program through the end of the 2021-22 academic year.

To celebrate its May Release, the Stanford China Program hosted a virtual book launch event for Fateful Decisions: Choices That Will Shape China’s Future (Stanford University Press) on June 2^nd. Joining co-authors Thomas Fingar (Shorenstein APARC Fellow, Stanford University) and Jean C. Oi (Director, Stanford China Program; William Haas Professor of Chinese Politics, Stanford University) were contributors Karen Eggleston (Senior Fellow at FSI; Director of the Asia Health Policy Program, Shorenstein APARC, Stanford University), Barry Naughton (Sokwanlok Chair of Chinese International Affairs, School of Global Policy and Strategy, UC San Diego), and Andrew Walder (Senior Fellow at FSI; Denise O'Leary and Kent Thiry Professor, Stanford University). As Fingar and Oi point out in their volume, despite China’s extraordinary growth over the past 40 years, the country’s future is uncertain. China has enjoyed optimal conditions for development since the 1980s, but new hurdles including an aging populace, the loss of comparative economic advantage, a politically entrenched elite, and a population with rising expectations will test the country’s leaders. With each focusing on a different facet of China’s challenges, the panelists gathered to share their expertise and provide the audience with a glimpse into what the future might hold for this important country.

Available Now: Fateful Decisions: Choices That Will Shape China’s Future

Following an introduction from Professor Jean Oi, the program kicked off with Professor Barry Naughton of University of California, San Diego, who discussed his chapter entitled “Grand Steerage.” Professor Naughton argued that, as it plans for the future, China’s policymaking is becoming increasingly technology-focused, particularly in the realm of economic policy. Naughton further notes that China’s economy is becoming simultaneously more state-guided and more centered around technology. This decision is a gamble, though: China is investing heavily in high-tech industries, advancing massive, centrally steered projects like the Greater Bay Area initiative and the Xiong’an New District. If they are successful, says Naughton, this will indeed be an incredible success. But, if they are not, China’s losses will be major: “There’s not really a middle ground.”

After Professor Naughton was Professor Karen Eggleston, an expert on health policy in Asia. Professor Eggleston’s chapter, “Demographic and Healthcare Challenges,” deals with emerging obstacles for China’s healthcare system, including population aging and the problems that come with it, like chronic diseases and elder care. Although China’s healthcare system has improved dramatically in recent decades, it has done so unevenly, notes Eggleston: life expectancy has greatly increased, but with disparities according to income, region, and urban vs. rural status; universal healthcare is available, but the benefit level is low, effectively limiting the standard of care many can receive. The ratio of health spending to GDP is also increasing, yet it is still modest compared to high-income countries. The COVID-19 crisis has, of course, introduced even more challenges: Will China be able to distribute future vaccines equitably? Will this crisis negatively affect young people’s decisions to choose healthcare as a career? Will telemedicine, which has seen a surge under the pandemic, improve or exacerbate existing disparities? China faces a multitude of constraints and choices going forward if it hopes to meet its population’s healthcare needs.

The audience then had a chance to hear from co-editor Thomas Fingar, speaking on his chapter, “Sources and Shapers of China’s Foreign Policy.” Fingar noted three key takeaways from both his chapter and his talk: Firstly, China’s foreign policy is a fundamental part of its national policy. Secondly, the global political environment plays an important role in shaping both foreign and domestic policy which, thirdly, plays an important role in shaping foreign policy. The conditions that allowed China to flourish over the past 40 years, emphasized Fingar, are very different from those of the present. In the 1970s and 80s, China was able to take advantage of Cold War bipolarity, globalization was in its infancy, and “China was the only significant developing country willing to embark, at that time, on the export-led path of development.” In recent years, though, China’s behavior internationally has alienated other countries; there are many competitors pursuing its style of development; and its needs and aspirations have changed, requiring more raw materials and depending upon multi-national economic agreements. Fingar suggests two potential foreign policy options: China could continue with its wolf warrior diplomacy, which has “alienated essentially all China’s neighbors to some degree,” or it could return to a style more similar to that of the 1980s and 90s Reform and Opening era. It remains to be seen which style will win out.

Finally, Professor Andrew Walder concluded the program with his discussion of China’s political future at large. His chapter, “China’s National Trajectory,” follows China’s remarkable advancement in recent years and “tr[ies] to divine what a lower growth era will mean for China’s political future.” The last 40 years of rapid growth have generated support for China’s political system, more patriotism, the near eradication of democracy movements, and an elite unity not seen in the 1970s and 80s. However, low growth rates could mean a reversal for many of these trends, says Walder. While the aforementioned support for and stability of the Chinese government was maintained by ever-improving living standards and upward mobility, a low growth period (coupled with an aging population) means the government will no longer be able to rely on these trends for popular support. Rather, it will need to improve its provision of public services to address present-day challenges. Regardless, argues Walder, the low growth era will undoubtedly lead to “dynamic changes underneath the façade of stability of Chinese politics….”

For more insights on the modern obstacles China faces and what they mean for the country’s future, check out Fateful Decisions: Choices That Will Shape China's Future, available for purchase now.

What are the Chinese government’s objectives for the development of its healthcare system? How do these ambitions affect its interaction with U.S. and other foreign healthcare markets? And what policy recommendations should lawmakers consider regarding the development of China's healthcare system and its implications for U.S. national interests? These are some of the questions that APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston discussed in her testimony before the U.S.-China Economic and Security Review Commission on May 7, 2020.

Watch Eggleston’s testimony (start time 23:25]