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Cited by 914Primary Care and Health OutcomesHealthcare Systems and PracticesHealthcare Systems and Reforms

Quality of primary health care in China: challenges and recommendations

Open access
Li, Xi, Krumholz, Harlan M, Yip, Winnie, Cheng, Kar Keung, De Maeseneer, Jan, Meng, Qingyue, Mossialos, Elias, Li, Chuang +24 more·2020·The Lancet
DOI 10.1016/s0140-6736(20)30122-7PMC PMC7272159
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Abstract

China has substantially increased financial investment and introduced favourable policies for strengthening its primary health care system with core responsibilities in preventing and managing chronic diseases such as hypertension and emerging infectious diseases such as coronavirus disease 2019 (COVID-19). However, widespread gaps in the quality of primary health care still exist. In this Review, we aim to identify the causes for this poor quality, and provide policy recommendations. System challenges include: the suboptimal education and training of primary health-care practitioners, a fee-for-service payment system that incentivises testing and treatments over prevention, fragmentation of clinical care and public health service, and insufficient continuity of care throughout the entire health-care system. The following recommendations merit consideration: (1) enhancement of the quality of training for primary health-care physicians, (2) establishment of performance accountability to incentivise high-quality and high-value care; (3) integration of clinical care with the basic public health services, and (4) strengthening of the coordination between primary health-care institutions and hospitals. Additionally, China should consider modernising its primary health-care system through the establishment of a learning health system built on digital data and innovative technologies.

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  • China's high-volume, hospital-centred health care system, often marked by fragmented care pathways and limited integration with community services, poses challenges for ensuring continuity of care for family caregivers.

    “China's high-volume, hospital-centred health care system—often marked by fragmented care pathways and limited integration with community services—poses challenges for ensuring continuity of care for family caregivers.”

    From The burdens, coping strategies, and unmet needs of family caregivers of Chinese patients with lymphoma receiving commercial CAR-T-cell therapy: A qualitative study (2026) · cites this paper as [73]

    The Introduction describes China’s delivery system as hospital-centric, and the Coordination and Continuity of care sections describe weak integration between hospitals and primary care, fragmented records, and barriers to continuity across care sites. The passages concern continuity of patients’ care, not continuity of care for family caregivers; that extension is not supported by our copy. Page numbers were not provided. (LLM, conf=0.87)

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Research works printed but not linked: 44

  1. [1]Chen Z Launch of the health-care reform plan in China Lancet 373 2009 1322 1324 19376436
  2. [5]Li X Lu J Hu S The primary health-care system in China Lancet 390 2017 2584 2594 29231837
  3. [7]Yip W Fu H Chen AT 10 years of health-care reform in China: progress and gaps in Universal Health Coverage Lancet 394 2019 1192 1204 31571602
  4. [8]Li Z Hou J Lin L Tang S Jin M On residents' satisfaction with community health services after health care system reform in Shanghai, China, 2011 BMC Public Health 12 suppl 1 2012 S9 22992209 PMC3381687
  5. [9]Donabedian A The quality of care. How can it be assessed? JAMA 260 1988 1743 1748 3045356
  6. [10]Kringos DS Boerma WG Bourgueil Y The European primary care monitor: structure, process and outcome indicators BMC Fam Pract 11 2010 81 20979612 PMC2975652
  7. [11]Su M Zhang Q Lu J Protocol for a nationwide survey of china's primary health care: the China PEACE MPP Primary Health Care Survey BMJ Open 7 2017 e016195 PMC5629739 28851781
  8. [12]Liang J Li X Kang C Maternal mortality ratios in 2852 Chinese counties, 1996–2015, and achievement of Millennium Development Goal 5 in China: a subnational analysis of the Global Burden of Disease Study 2016 Lancet 393 2019 241 252 30554785 PMC6336935
  9. [14]Sylvia S Shi Y Xue H Survey using incognito standardized patients shows poor quality care in China's rural clinics Health Policy Plan 30 2015 322 333 24653216
  10. [15]Sylvia S Xue H Zhou C Tuberculosis detection and the challenges of integrated care in rural China: a cross-sectional standardized patient study PLoS Med 14 2017 e1002405 PMC5644979 29040263
  11. [16]Daniels B Kwan A Pai M Das J Lessons on the quality of tuberculosis diagnosis from standardized patients in China, India, Kenya, and South Africa J Clin Tuberc Other Mycobact Dis 16 2019 100109 PMC6830154 31720433
  12. [17]Li Y China's misuse of antibiotics should be curbed BMJ 348 2014 g1083 24523392
  13. [18]Li Y Xu J Wang F Overprescribing in China, driven by financial incentives, results in very high use of antibiotics, injections, and corticosteroids Health Aff (Millwood) 31 2012 1075 1082 22566449
  14. [19]Yip W Powell-Jackson T Chen W Capitation combined with pay-for-performance improves antibiotic prescribing practices in rural China Health Aff (Millwood) 33 2014 502 510 24572187
  15. [20]Yin X Song F Gong Y A systematic review of antibiotic utilization in China J Antimicrob Chemother 68 2013 2445 2452 23800903
  16. [22]Wang J Wang P Wang X Zheng Y Xiao Y Use and prescription of antibiotics in primary health care settings in China JAMA Intern Med 174 2014 1914 1920 25285394
  17. [23]Zhang X Cui Y Liu C Zuo K Tang Y Antibiotic sales in primary care in Hubei province, China: an analysis of 2012–2017 procurement records Int J Environ Res Public Health 16 2019 3376 PMC6765864 31547325
  18. [24]Xiao Y Antimicrobial stewardship in China: systems, actions and future strategies Clinical Infectious Diseases 67 suppl 2 2018 S135 S141 30423041
  19. [25]Lu J Lu Y Wang X Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project) Lancet 390 2017 2549 2558 29102084
  20. [26]Su M Zhang Q Bai X Availability, cost, and prescription patterns of antihypertensive medications in primary health care in China: a nationwide cross-sectional survey Lancet 390 2017 2559 2568 29102087
  21. [29]Lu J Lu Y Wang X Prevalence, awareness, treatment, and control of hypertension in China: data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project) Lancet 390 2017 2549 2558 29102084
  22. [30]Li Y Yang L Wang L Burden of hypertension in China: a nationally representative survey of 174 621 adults Int J Cardiol 227 2017 516 523 27856040
  23. [31]Wang Z Chen Z Zhang L Status of hypertension in China: results from the China hypertension survey, 2012–2015 Circulation 137 2018 2344 2356 29449338
  24. [34]Wang L Gao P Zhang M Prevalence and ethnic pattern of diabetes and prediabetes in China in 2013 JAMA 317 2017 2515 2523 28655017 PMC5815077
  25. [40]Wong WCW Jiang S Ong JJ Bridging the gaps between patients and primary care in china: a nationwide representative survey Ann Fam Med 15 2017 237 245 28483889 PMC5422085
  26. [41]Meng Q Yang h Chen W Sun Q Liu X People's Republic of China health system review 2015 World Health Organization Geneva, Switzerland
  27. [42]Liang S Deng H Liu S Competency building for lay health workers is an intangible force driving basic public health services in Southwest China BMC Health Serv Res 19 2019 596 31443648 PMC6708187
  28. [44]Yi H Miller G Zhang L Li S Rozelle S Intended and unintended consequences of China's zero markup drug policy Health Aff (Millwood) 34 2015 1391 1398 26240254
  29. [45]Zhu J Study on the influence of zero-profit drug policy on the economic operation and medical expenses of primary health care institutions Master's thesis 2012 Anhui Medical University
  30. [46]Qin L Jiang Z Public financial support and behavioral distortion of rural primary medical service Review of Economic Research 67 2011 38 42
  31. [47]Tian L Research on the operating cost and compensating mechanism of basic medical institutions in Jilin province Master's thesis 2015 Jilin University
  32. [50]Zhang P Zhao L Liang J Societal determination of usefulness and utilization wishes of community health services: a population-based survey in Wuhan city, China Health Policy Plan 30 2015 1243 1250 25492032 PMC4625757
  33. [53]Guo L Bao Y Ma J Quality of community basic medical service utilization in urban and suburban areas in Shanghai from 2009 to 2014 PLoS One 13 2018 e0195987 PMC5965823 29791470
  34. [54]Li W Gan Y Dong X Gatekeeping and the utilization of community health services in Shenzhen, China: a cross-sectional study Medicine (Baltimore) 96 2017 e7719 PMC5617687 28930820
  35. [58]Khan MS Wu S Wang X Coker R Optimising routine surveillance systems for informing tuberculosis control policies in China Health Policy and Planning 32 suppl 2 2017 ii12 ii14 29028225
  36. [60]Liu C Wu Y Chi X Relationship preferences and experience of primary care patients in continuity of care: a case study in Beijing, China BMC Health Serv Res 17 2017 585 28830507 PMC5568350
  37. [61]Meng Q Yang H Chen W Sun Q Liu X People's Republic of China health system review Health Syst Transit 5 2015
  38. [62]Jiang L Krumholz HM Li X Li J Hu S Achieving best outcomes for patients with cardiovascular disease in China by enhancing the quality of medical care and establishing a learning health-care system Lancet 386 2015 1493 1505 26466053 PMC5323019
  39. [65]Strasser R Cheu H Needs of the many: Northern Ontario School of Medicine students' experience of generalism and rural practice Can Fam Physician 64 2018 449 455 29898937 PMC5999254
  40. [66]De Maeseneer J Boeckxstaens P James Mackenzie Lecture 2011: multimorbidity, goal-oriented care, and equity Br J Gen Pract 62 2012 e522 e524 22782000 PMC3381278
  41. [67]Zhan Q Shang S Li W Chen L Bridging the GP gap: nurse practitioners in China Lancet 394 2019 1125 1127 31571590
  42. [68]Magill MK Time to do the right thing: end fee-for-service for primary care Ann Fam Med 14 2016 400 401 27621155 PMC5394371
  43. [71]Yuan S Wang F Zhao Y Liu Y Assessing perceived quality of primary care under hospital-township health centre integration: a cross-sectional study in China Int J Health Plann Manage 35 2019 e196 e209 31713280
  44. [76]World Organization of National Colleges Academies and Academic Associations of General Practitioners/Family Physicians ICPC-2: international classification of primary care 1998 OUP Oxford Oxford

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Authors
Li, X., Krumholz, H. M., Yip, W., Cheng, K. K., De Maeseneer, J., Meng, Q., Mossialos, E., Li, C., Lu, J., Su, M., Zhang, Q., Xu, D. R., Li, L., Normand, S.-L. T., Peto, R., Li, J., Wang, Z., Yan, H., Gao, R., Chunharas, S., Gao, X., Guerra, R., Ji, H., Ke, Y., Pan, Z., Wu, X., Xiao, S., Xie, X., Zhang, Y., Zhu, J., Zhu, S., & Hu, S.
Affiliations
  • Chinese Academy of Medical Sciences & Peking Union Medical College (CN)
  • Yale New Haven Hospital (US)
  • Harvard University (US)
  • Peking University (CN)
  • Imperial College London (GB)
  • Public Hygiene and Health Commission of Shenzhen Municipality (CN)
  • Sun Yat-sen University (CN)
  • University of Oxford (GB)
  • World Health Organization (CH)
  • Shanghai Medical College of Fudan University (CN)
  • Sichuan Center for Disease Control and Prevention (CN)
  • Central South University (CN)
  • Sichuan University (CN)
Corresponding author
Hu, Shengshou
ORCID
Venue
The Lancet
Publisher
Elsevier BV
Published
2020-06
Volume
395
Issue
10239
Pages
1802-1812
ISSN
  • 0099-5355 (ISSN-L)
  • 0140-6736
DOI
10.1016/s0140-6736(20)30122-7
PMC
PMC7272159
OpenAlex
W3016826869
Cited by
914
References
1
Citations by year
2026: 139 · 2025: 172 · 2024: 193 · 2023: 155 · 2022: 136 · 2021: 92 · 2020: 26 · 2016: 1
FWCI
19.54
Type
journal article
Language
en
Open access
Licence
Locations
  • The Lancet (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Ghent University Academic Bibliography (Ghent University) (submittedVersion)
  • University of Birmingham Research Portal (University of Birmingham) (submittedVersion, cc-by-nc-nd)
Funders
  • World Health Organization
  • Yale University
  • London School of Economics and Political Science
  • University of Birmingham
  • Ministry of Education of the People's Republic of China (‘111’ Project, B16005)
  • National Health and Family Planning Commission of the People's Republic of China
  • Chinese Academy of Medical Sciences (2016-12M-1-006, 2017-I2M-2-002, 2017-I2M-1, 2017-I2M-1-003)
  • Peking University
  • Higher Education Discipline Innovation Project (B16005)
  • National Institutes of Health (UL1TR001863)
  • Peking University Health Science Center
  • National Center for Advancing Translational Sciences
Topics
  • Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
  • Health Sciences › Health Professions › General Health Professions › Healthcare Systems and Practices
  • Social Sciences › Economics, Econometrics and Finance › Finance › Healthcare Systems and Reforms
Keywords
primary care quality, China, chronic disease prevention, hypertension, COVID-19 pandemic, fee-for-service, care fragmentation, continuity of care, performance accountability, learning health systems, digital health data
MeSH terms
COVID-19, China, Continuity of Patient Care, Humans, Pneumonia, Viral, Primary Health Care, Quality of Health Care, Coronavirus Infections, Fee-for-Service Plans, Physicians, Primary Care, Pandemics

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