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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.

When Siyan Yi was a medical student in Cambodia 12 years ago, he volunteered with a collaborative government-NGO project to provide young women at high risk for HIV/AIDS—the victims of sexual exploitation—with housing, vocational training, medical care, and psychological support. Cambodia at that time had one of Asia’s highest HIV-infection rates.

That rate has dropped by half, thanks to government policy measures, international NGO support, and the efforts of medical professionals like Yi. Cambodia’s government must now find ways to curb HIV infection in new segments of the population, says Yi, who is the Shorenstein Asia-Pacific Research Center’s inaugural Developing Asia Health Policy Fellow. Sustaining funding for the long-term care of HIV-infected individuals also poses a future challenge, he explains, and new health issues associated with development are beginning to crop up.

Cambodia’s first HIV case was detected in 1991 in a blood donor, and the rate of HIV/AIDS increased dramatically throughout the decade. HIV/AIDS hit Thailand slightly earlier, and was spread through the commercial sex trade. The epidemic reached an even greater scale there than it ever did in Cambodia.

Thailand’s government struck back with a 100-percent condom use promotion program, which Cambodia successfully adopted in the late 1990s. Brothels are illegal in Cambodia, but the government worked cooperatively with owners to provide basic HIV/AIDS education to sex workers. These efforts significantly reduced the transmission of HIV.

Since then, a more indirect form of prostitution has sprung up in places such as karaoke halls, massage parlors, restaurants, and even in factories. HIV prevalence remains high among some sentinel groups such as female sex workers, beer promoters, men who have sex with men (MSM), injected-drug users, and migrant workers.

Yi advocates that the government expand the scope of its HIV/AIDS prevention programs to encompass these new at-risk populations. He even suggests that the government consider creating a system of licensed brothels such as previously existed in Hong Kong and Taiwan. “It would provide the government with an easier means of controlling prostitution, and allow it to work with brothel owners to control HIV-infection rates,” states Yi.

HIV increases the risk of contracting or developing symptoms of tuberculosis; a large proportion of Cambodia’s population carries the disease but shows no signs of it. Tuberculosis went largely undetected during the decades of the Khmer Rouge regime, but with the advent of HIV/AIDS it has become more prevalent. Yi has been involved in government-NGO projects to provide tuberculosis screening for HIV patients, including a tuberculosis control project with the Japan International Cooperation Agency.

Tuberculosis screening and HIV treatment advances may greatly prolong the life—and even improve the health—of patients. But heartening as Cambodia’s success against HIV/AIDS has proven in the past decade, the government largely bears the responsibility for funding the expensive treatment and care for the low-income individuals most affected by it. A critical portion of government funding for its HIV/AIDS prevention programs comes from external organizations. 

“I think that the main issue for the government of Cambodia in the battle against HIV and AIDS is financial sustainability,” says Yi, who worries that donor agencies will withdraw support as the HIV-infection rate continues to improve. Prevention is less expensive, he explains, but long-term care is costly to a developing country such as Cambodia.

Yi, however, feels less concerned now about the HIV/AIDS epidemic and speaks hopefully of working to help the government find ways to measure and treat non-communicable diseases associated with economic development, such as diabetes and hypertension. While he is at Stanford, he will collaborate with Asia Health Policy Program researchers to move his work toward solving Cambodia’s new health challenges.