Policy &Policy practice & practice

People-centred integrated care in urban Xin Wang,a Xizhuo Sun,b Stephen Birch,c Fangfang Gong,b Pim Valentijn,d Lijin Chen,a Yong Zhang,a Yixiang Huanga & Hongwei Yange

Abstract In most countries, the demand for integrated care for people with chronic diseases is increasing as the population ages. This demand requires a fundamental shift of health-care systems towards more integrated service delivery models. To achieve this shift in China, the World Health Organization, the World Bank and the Chinese government proposed a tiered health-care delivery system in accordance with a people-centred integrated care model. The approach was pioneered in Luohu of city from 2015 to 2017 as a template for practice. In September 2017, China’s health ministry introduced this approach to people-centred integrated care to the entire country. We describe the features of the Luohu model in relation to the core action areas and implementation strategies proposed and we summarize data from an evaluation of the first two years of the programme. We discuss the challenges faced during implementation and the lessons learnt from it for other health-care systems. We consider how to improve collaboration between institutions, how to change the population’s behaviour about using community health services as the first point of contact and how to manage resources effectively to avoid budget deficits. Finally, we outline next steps of the Luohu model and its potential application to strengthen health care in other urban health-care systems.

The World Health Organization (WHO) describes Introduction people-centred integrated care as health services that are managed and delivered so that patients receive a continuum On 1 September 2017, China’s health ministry introduced a of preventive and curative services according to their needs new approach to people-centred integrated care to the entire over time that is coordinated across different levels of the country.1 Called the Luohu model, the approach was pioneered health-care system.16–19 Over the last decade, integrated in Luohu district of Shenzhen city. This development was a care has been suggested as one strategy for promoting response to the problems faced by the existing health-care coordinated health-care delivery, improving quality of system in addressing the increased demands of delivering care and reducing costs.20,21 In 2016, the report Deepening integrated care.2,3 Health-care systems worldwide are facing health reform in China was published jointly by the WHO, similar problems emerging from epidemiological transition the World Bank and the Chinese government.15 The report and population ageing.4–6 Many people-centred integrated proposed strengthening health care in China through a care programmes have been initiated, implemented and evalu- tiered health-care delivery system in accordance with a ated in high-income countries. While experience from other people-centred integrated care model. countries provides a useful basis for planning,7,8 the ability to The introduction of the Luohu model set an example for achieve people-centred integrated care can be highly context- urban areas in China to build people-centred integrated care specific8,9 and there is a lack of knowledge about how to stimu- delivery systems. This represented a big step in pursuing higher late integrated care in low- and middle-income countries.10 quality health care, better outcomes and more affordable costs The current system of health-care delivery in China is for the population in China. In this paper, we describe the fragmented, hospital-centred and treatment-dominated, with features of the Luohu model, discuss lessons learnt from its little effective collaboration among institutions in different implementation and outline next steps for the Luohu model tiers of the system.3,11,12 In 2016, there were an estimated 231 and its application in other Chinese urban health-care systems. million people aged 60 years or older in China, 16.7% of the We also provide suggestions on adapting the Luohu model in population of 1 383 billion, and more than 100 million among other low- and middle-income countries. them had at least one chronic noncommunicable disease.13,14 Predictions suggested that without health-care reform, China’s health-care costs in United States dollars (US$) would increase The Luohu model from 5.6% of gross domestic product in 2015 (US$ 592 billion Background of US$ 10 571 billion) to 9.1% in 2035 (US$ 2713 billion of US$ 29 810 billion).15 System reform was therefore viewed as The Luohu model was a response to the needs of patients and necessary to avoid the risk of becoming a high-cost, low-value their families in Luohu district (Health and Family Planning health-care system. Commission of Shenzhen city, unpublished data, 2015). With

a School of Public Health, SUN Yat-sen University, No. 74, 2nd Road, , 510080, China. b Shenzhen Luohu Hospital Group, Shenzhen, China. c Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia. d Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands. e China National Health Development Research Centre, Beijing, China. Correspondence to Yixiang Huang (email: [email protected]). (Submitted: 22 April 2018 – Revised version received: 7 September 2018 – Accepted: 7 September 2018 – Published online: 1 October 2018 )

Bull World Health Organ 2018;96:843–852 | doi: http://dx.doi.org/10.2471/BLT.18.214908 843 Policy & practice People-centred care in urban China Xin Wang et al. a population of around 1.47 million in In February 2015, the Luohu gov- care to become the first point of an area of 78 km2, Luohu is the most ernment initiated a health-care reform contact; (ii) multidisciplinary teams; densely populated district of Shenzhen programme in cooperation with the lo- (iii) vertical integration; (iv) horizontal city, province. In 2014, over cal ministries in Shenzhen (the Health integration; (v) eHealth; (vi) integrated 451 000 people were estimated to live and Family Planning Commission, Min- clinical pathways and dual referral with chronic diseases in Luohu (Gong istry of Human Resources and Social systems; (vii) measurement and feed- F, Luohu hospital group, unpublished Security, and Ministry of Finance). The back; and (viii) certification and their data, 2014). There was a city hospital stated goals of the Luohu people-centred accompanying strategies to achieve with 2000 beds, five district-level public integrated care model were better servic- people-centred integrated care.15 The hospitals with a total of 1172 beds and es, less illness, fewer hospital admissions Luohu model implemented all the sug- 83 community health stations provid- and lower financial burdens. In August gested core actions except certification ing ambulatory care in the district. The 2015, an integrated organization – the (Table 1). growing size of the city hospital result- Luohu hospital group – was established, First, under the Luohu model, pa- ed in increasing numbers of patients at- comprising five district-level hospitals, tients are encouraged to sign a contract tending. Since patients had greater trust 23 community health stations and an in- with a general practitioner based at a in providers at the city-level hospital stitute of precision medicine. A council community health station and use him than the community health stations, composed of government officials and or her as the first point of contact with they often sought services directly at representatives from local communities the Luohu hospital group. However, the hospital despite receiving a lower managed the group with the support of the gatekeeping system is not manda- reimbursement of medical expenses. a local supervisory board, expert com- tory and allows an element of choice Furthermore, many patients stayed in mittee and workers’ congress. The group for patients. hospital for post-acute care rather than established six resource-sharing centres Second, in community health sta- accessing this care in community health and six administrative centres (Fig. 1) tions each primary health-care team stations, because city- and district-level by reorganizing the relevant centres of consists of essential members: a general hospitals and community health sta- the previous 29 institutions, to improve practitioner, a nurse, a public health tions operated independently and com- the efficiency of both resource use and physician and a health promotion peted for patients. The government of administration. practitioner. Teams may also include Shenzhen city and Luohu district were Actions and strategies a pharmacist, psychologist or other concerned about the unmet needs of specialist physician (e.g. geriatrician, the population and the increased health The policy report Deepening health paediatrician, internist) according to expenditure associated with inappro- reform in China recommended eight the needs of local residents. General priate hospital use and lengths of stay. core action areas: (i) primary health practitioners lead in developing team

Fig. 1. Organizational structure of the Luohu hospital group, Shenzhen city, China

Supervisory board Expert committee Supervise Recall

Manage Recall Council Luohu hospital group Workers’ congress

Party committee President Accountant

5 hospitals 1 institute of 6 resource-sharing 6 administrative 23 community medicine centres centres health stations

Zhongxun Traditional General Medical Human precision Quality Chinese hospital testing centre resources medical Radiography management medicine centre institute centre centre hospital Maternity and child Disinfection Financial health-care and supply centre Rehabilitation hospital Information centre Research and hospital centre education centre Community health Health Geriatric stations management hospital Logistic and General management centre distribution management centre centre centre

844 Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 Policy & practice Xin Wang et al. People-centred care in urban China priorities, patient goals and care plans, records in their own system. With the review their personal performance and and approve test orders, medication and help of a Chinese internet company, identify problems which are then used referrals. Luohu hospital group designed a new to drive continuous improvement. Third, the Luohu hospital group computer application called Healthy Preliminary evaluation comprises 29 institutions at the com- Luohu, which all health-care providers munity and district levels. In this vertical can access. Patients too can access their According to the annual self-evalu- network, district-level hospitals focus on own medical records online. ations of the Luohu hospital group, providing complex care and emergency Sixth, there is a referral gateway 575 012 residents (around 39% of the care for life-threatening situations. between community health stations population) had signed contracts with Community health stations provide and hospitals in the group. Patients primary health-care teams by July 2017. health promotion, preventive care, case can be referred from community From June 2015 to June 2017 increasing management and medical care for com- health stations to hospitals for expe- proportions of the population used ser- mon diseases. dited care or can be referred back from vices in the Luohu hospital group rather Fourth, multidisciplinary primary hospitals for continuous rehabilitation than other hospitals outside the group health-care teams help to integrate dif- care and follow-up within primary after establishment of the integrated ferent types of care. Health promotion care. Patients referred via the gateway care programmes (Fig. 2). Increasing staff was recruited from the former fam- do not need to go through the hospital number of patients with diabetes, hy- ily planning stations to provide health patient registration process and are pertension and severe mental illness are education for patients. Public health given priority for care in the hospital now under integrated case management physicians working at the Chinese Cen- compared with those directly access- (Fig. 3), which reflects greater collabo- ter for Disease Control and Prevention ing the hospital. ration between district-level hospitals provide services such as, responding to Seventh, the Luohu hospital group and community health stations. From and reporting infectious diseases and established a performance measure- 2015 to 2017 the administration ex- public health emergencies and monitor- ment system. The general manage- penses of the whole group reduced by ing domestic water supplies. ment centre is responsible for making 19% (from US$ 30.0 million to US$ Fifth, hospitals and community annual evaluations of performance 24.3 million), and the average salary health stations previously used two dif- using data collected by the informa- of staff in community health stations ferent electronic information systems tion centre (Fig. 1). The results are increased by 10% (from US$ 26 915 to and providers could only view patient communicated back to stakeholders to US$ 29 607). Furthermore, a survey of

Table 1. Core actions and strategies to achieve people-centred integrated care in Luohu district, Shenzhen city, China

Core action Implementation Imple- Specific description in the Luohu model Document reference areaa strategiesa mented? Primary care as Patient Yes Residents in Luohu district are encouraged to sign a Luohu government resolution first contact registration contract with a general practitioner voluntarily. The no. 24 [2015]: agreement defines a package of services, the service Implementation plan for delivery process, and the rights and obligations of both comprehensive reform of patient and provider. public hospitals in Luohu Contract period is one year with a specific general district practitioner. At the end of the period the patient can sign a contract with another general practitioner, which allows some element of patient choice. Risk stratification Under Previous electronic information systems could not NA preparation support risk stratification. Luohu hospital group is preparing to collect data for a risk stratification exercise based on disease burden, using a new computer application program. Gatekeeping Yes Patients are strongly encouraged to see their primary Luohu government resolution health-care provider before a visiting a hospital no. 24 [2015]: specialist. However, they are not formally required to do Implementation plan for so. comprehensive reform of To promote patients’ use of family medical practices as public hospitals in Luohu the first contact, district-level hospitals assign specialists district to work temporarily in community health stations. Ensuring Yes Home visits are provided for patients who sign a contract National Health and Family accessibility with a general practitioner, especially for the elderly Planning Commission of people. Luohu district resolution no. 67 [2015]: Implementation plan for home visits in Luohu district

(continues. . .)

Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 845 Policy & practice People-centred care in urban China Xin Wang et al.

(. . .continued) Core action Implementation Imple- Specific description in the Luohu model Document reference areaa strategiesa mented? Multidisciplinary Team Yes In community health stations, each primary care team Luohu government resolution teams composition, consists of a general practitioner (leader), nurse, public no. 5 [2017]: roles and health physician and health promotion practitioner and Lessons learnt from the leadership may also include specialist physicians (e.g. geriatrician, Luohu model to promote the paediatrician, internist), pharmacist, nutritionist or construction of district hospital psychologist. group in Shenzhen The roles of each member are clearly defined, with flexibility to adjust roles based on patients’ needs and the context. Individual care Under The hospital group is preparing to use care plans for NA plans for patients preparation high-risk patients identified by a risk stratification approach. Vertical Definition Yes The Luohu model defines the roles of each component Luohu government resolution integration of facility of the hospital group to ensure coordination. no. 24 [2015]: roles within District-level hospitals are centres of excellence in Implementation plan for a vertically technology and staff expertise, focusing on providing comprehensive reform of integrated high complexity of care and valuable rescue care for public hospitals in Luohu network life-threatening situations. District hospitals also provide district technical assistance and training to community health Luohu hospital group stations. resolution no. 3 [2017]: Community health stations focus on providing Charter of the Luohu hospital preventive care, rehabilitation, case management and group (revised version of 2017) medical care for common diseases Luohu government resolution no.5 [2017]: Lessons learnt from the Luohu model to promote the construction of district hospital group in Shenzhen Provider- Yes In the hospital group, provider-to-provider relationships to-provider are strengthened through technical assistance and relationships capacity-building. District-level hospitals are responsible to provide clinical technical assistance through training, education and joint consultations to physicians in community health stations. Meanwhile, physicians in community health stations are encouraged to get three months of training in the hospitals Forming facility Yes The hospital group was established in the form of an networks independent corporation consisting of 23 community health stations, five district hospitals and an institute of precision medicine (which mainly provides diagnostic testing). A council of government officials and representatives from local communities was set up, to which the group are accountable to. Six administrative centres were re-organized using the resources of the respective centres in the former five district- level hospitals. Twelve centres provide resources and management for the whole group Horizontal Integrating of Yes The multidisciplinary primary health-care teams National Health and Family integration different types include former health promotion staff from family Planning Commission of Luohu of care planning stations, public health physicians from the district resolution no. 4 [2016]: Chinese Center for Disease Control and Prevention and Implementation plan for specialists from hospitals. Teams work cooperatively appointing public health with other members to provide preventive care, physicians to work in screening, diagnosis, treatment, rehabilitation and case community health stations management for patients. Six resource-sharing centres (human resources, quality management, financial, research and education, community health station management and general management; Fig. 1) allow for more efficient use of resources through reducing care overlap

(continues. . .)

846 Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 Policy & practice Xin Wang et al. People-centred care in urban China

(. . .continued) Core action Implementation Imple- Specific description in the Luohu model Document reference areaa strategiesa mented? E-Health Integrated Yes The hospital group designed the Healthy Luohu Luohu government resolution electronic computer application. By logging into their personal no. 24 [2015]: medical records account, both providers and patients can access Implementation plan for systems electronic health records systems comprehensive reform of public hospitals in Luohu district Communication Yes The Healthy Luohu application allows patients to request and care an online appointment with a specific physician in all management institutions. Staff in community health stations can make functions an online referral for patients to hospitals. The application is also easy for patients to check physician information and update registration and payment forms Interoperability Under Providers in hospitals and community health stations NA of e-health preparation can view patient records in their own institution. Luohu across facilities hospital group is establishing regulations to allow the and services electronic systems to link across institutions securely and effectively Integrated Integrated Under Clinical pathways are being created to standardize the NA clinical clinical pathways preparation treatment and referral pathways between providers pathways and for care dual referral integration and decision support Dual referral Yes In the referral gateway model, patients referred from Luohu government resolution pathways within community health stations are expected to receive no. 24 [2015]: integrated care expedited care in the district-level hospitals. Implementation plan for networks Down-referral, which allows referrals of patients from comprehensive reform of hospital to community health stations for rehabilitation public hospitals in Luohu care or follow-up, is incentivized by a new health district insurance payment system in the Luohu hospital group Measurement Standardized Yes The Luohu hospital group established a performance Luohu government resolution and feedback performance measurement system and makes annual self-evaluations. no. 24 [2015]: measurement Indicators focus on measures of capacity-building of Implementation plan for indicators staff at community health stations (e.g. numbers of staff comprehensive reform of working in the community health stations, numbers of public hospitals in Luohu outpatients) and obtaining patients’ experiences district Continuous Yes The results are communicated back to stakeholders at all feedback loops levels, early positive results and challenges are identified. to drive quality The hospital group is designing new strategies based on improvement measurement results of the last two years Certification Certification No NA NA criteria for local and national use Targets for No NA NA criteria and use to certify facilities NA: not applicable. a Core action areas and implementation strategies suggested by the policy report Deepening health reform in China.15 about 80% of residents in 10 districts Lessons learnt tals. Three reasons have been proposed found that satisfaction with health care for the fragmentation of services in in Luohu district ranked first among all Despite promoting care integration China: (i) fee-for-service payments; 10 districts in Shenzhen city.22 within the hospital group and first point (ii) fragmentation of financing; and The health ministry of China was of contact at community health stations, (iii) more generous health insurance satisfied with the results of the two- the Luohu model provided several les- for inpatient than outpatient services.23 year preliminary evaluation in Luohu. sons to overcome challenges during Other researchers suggested that effec- Recognizing that it was a comprehen- implementation. tive care integration can be achieved sive model adopting and combining Improving collaboration without the need for the formal integra- strategies from other initiatives, the tion of organizations.24–26 However, the ministry began introducing the Luohu The first challenge was how to improve establishment of the Luohu hospital model to urban areas nationwide on 1 collaboration between community group created a strategy of integration September 2017. health stations and district-level hospi- across organizations and played a key

Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 847 Policy & practice People-centred care in urban China Xin Wang et al.

Fig. 2. Use of integrated care in the Luohu hospital group, Shenzhen city, China, 2014–2017

45 Luohu hospital group established 40 35 30 25 20

% of people 15 10 5 0 Jun 2014 – Jun 2015 Jun 2015 – Jun 2016 Jun 2016 – Jun 2017 Years Population of Luohu 1 470 000 1 470 000 1 480 000 No. of people registered with Luohu hospital group NA 183 752 575 012 No. of hospitalizations of residents registered with Luohu hospital group 26 634 28 156 32 119 No. of outpatient visits in the Luohu hospital group 2 700 000 5 480 000 5 280 000

Outpatients making first contact with primary care Population registered with a general practitioner Inpatients hospitalized within hospital group NA: not applicable. Data source: Self-evaluations of the Luohu hospital group.

responsible for supervising physicians’ Fig. 3. Number of patients under integrated case management by condition in the Luohu hospital group, Shenzhen city, China, 2014–2017 practices. Second, the Luohu model integrates multiple sources of finances. Subsidies from the finance ministry 30 000 Luohu hospital group established for providing preventive care, health insurance funds from the social secu- 25 000 rity ministry, out-of-pocket payments from patients and payments from other 20 000 sources are all managed by the group’s fi- 15 000 nancial centre (Fig. 1). Third, the Luohu model ended the higher reimbursement

No. of patients No. 10 000 rate of inpatient services compared with outpatient services and incentivized 5000 patients to seek care first at community health stations. For example, in com- 0 munity health stations common drugs Jun 2014 Jun 2015 Jun 2016 Jun 2017 for chronic diseases are available at 70% Years of the prices in hospitals. Organizational Hypertension integration and the innovative Global Diabetes Budget, Balance Retained approach are Severe mental illness exemplars for other urban health-care Data source: Self-evaluations of the Luohu hospital group. systems in China. An important recommendation for role in removing these three barriers in Global Budget, Balance Retained. The adopting the model in other systems is the Luohu model. First, as illustrated by policy ended fee-for-service payment for that development and maintenance of others,23 the health ministry of China providers, with incentives for increasing a common frame of reference between has the responsibility for health care, service volumes, rather than improving organizations, professional groups and but no means to control the provision patient health outcomes.27 Instead, the individuals, is essential to promote col- of health services. The ministry cannot challenge was to balance the incentives laboration between different tiers of negotiate health insurance payment to the hospitals and community health the health-care system.26 In Shenzhen, reform with the social security ministry stations to work co-operatively to community health stations have been for individual institutions, but the entire strengthen preventive care and reduce affiliated with district hospitals since hospital group can. Luohu was the first demand for care. To avoid physicians 2011. This has provided a shared mission place to implement a new health insur- acting to reduce services, the qual- and management, and shared values that ance payment policy in China called ity management centre of the group is provide a foundation for mutual trust

848 Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 Policy & practice Xin Wang et al. People-centred care in urban China and collaboration across tiers. Trust in Luohu was also important for provid- health-care expenditure when calculat- needs to be built for collaboration be- ing the capacity to support integrated ing global budgets for hospital groups, tween institutions in other health-care care through the gatekeeper strategy. to avoid budget deficits in the first year. systems. During the period 2015–2017, the num- Changing patient behaviour ber of general practitioners in the group Next steps increased from 89 to 194, based on offer- The second challenge was how to change ing higher salaries and training in task- There are two remaining steps in the the behaviour of the population towards shifting for some specialists. In 2017, application of the Luohu model. First, using community health stations as the there were 3.02 general practitioners several strategies have not yet been first point of contact, rather than going per 10 000 residents in Luohu, compared implemented (Table 1), including risk to hospitals. In the Luohu model, four with an average of 1.38 per 10 000 for stratification, individual care plans for strategies were used to overcome this the entire country.22 Policymakers in patients, integrated clinical pathways cultural challenge. The first strategy was other health-care systems might con- for care integration, decision support capacity-building in community health sider general practitioner training of and certification. The Luohu hospital stations. Technical assistance from some specialists and task-shifting from group is preparing to implement a risk district-level hospitals contributed to the general practitioners to experienced stratification exercise based on disease improvement of care quality in commu- nurses and public health physicians to burden.22 Once high-risk patients have nity health stations. The second strategy fill the general practitioner gaps in the been identified, individual care plans was people-centred care in community short term. will be made. Clinical pathways are be- health stations. For example, in response Reducing costs ing created to standardize the treatment to the needs of elderly patients confined and referral pathways between provid- to bed, the community health stations The third challenge was how to avoid ers and to integrate care and support provided home visits to avoid unneces- budget deficits in the first year. The decision-making. Second, monitoring sary hospital admissions and maintain goal of lower financial burdens has not and evaluation is necessary to determine patients at home, while reducing the been achieved in the first two years the effectiveness of the Luohu model burden of care on family members. of the Luohu model. The 2016 global over time. Despite the new self-evalua- The third strategy was ensuring ad- budget of the Luohu model was given tion system, more indicators related to equate supplies of common drugs in by the total cost of health insurance for people-centred care, population health community health stations. According registered residents in the previous year, and financial burden over the long-term to a study of 22 city-level hospitals in multiplied by the average growth rate are required. Although residents’ satis- Beijing, one-third of patients attended of the health insurance fund in 2016. faction with health care in Luohu district hospitals solely to receive drugs (num- However, the average cost of integrated was high, their experience of integrated bers not stated).28,29 In the Luohu model, care per registered resident in the group care was not a focus of the present study, district-level hospitals shared all drugs increased from US$ 675.3 in 2015 to even though it is an essential part of with community health stations, which US$ 844.2 in 2016. The deficit arose the Luohu model. Nevertheless, we are reduced unnecessary outpatient visits because the global budget was based on planning to use patient-reported experi- to hospitals. Finally, health promotion medical costs in previous years, rather ences as a measure for integrated care to staff in primary health-care teams have than the costs of all aspects of integrated evaluate the Luohu model. Evaluation sought to improve health literacy in the care. Cost of preventive and other public results, in turn, will influence the imple- population since establishment of the health care, such as cancer screening mentation of the remaining strategies or hospital group. The proportion of the programmes for residents older than care integration. population with basic health literacy in 50 years and pneumonia vaccination for Although the health ministry rolled Luohu increased from 9.3% (136 710 of residents older than 60 years old, were out the Luohu model to other urban ar- 1.47 million) to 21.3% (315 240 of 1.48 not included. The finance ministry of eas of China, it will take time before the million) in the first two years of the pro- Shenzhen city made up for the budget model is implemented nationwide. From gramme.30 This compares with a national deficit of the hospital group by reorga- September to December 2017, more figure of 11.6% in a survey of 84 987 nizing health expenditure for public than 1500 policymakers from health and people in 2016.31 Health literacy enables health providers.32 Before establishment other social sectors in 321 cities received people to increase control over their of the hospital group, public health care on-site training in Luohu. The concept health and health determinants, while was mainly provided by three kinds of and mechanism of the Luohu model health promotion activities promote facilities: specialized public health-care were adopted by most cities in China. mutual trust between the population facilities (including disease prevention However, some strategies could not be and staff of community health stations. and control facilities, and health super- implemented in some cities, due to lack We therefore believe that improving the vision facilities); primary health care of resources and lack of support from population’s health literacy contributed facilities (community health stations); the of finance ministry and the social to changing attitudes and behaviour and hospitals.33,34 The ministry recalcu- security ministry. For example, insuf- about using community health stations lated the budget of public health care in ficient numbers of general practitioners in Luohu. 2017 for the hospital group based on the may delay the development of primary These four strategies could be ap- care provided in 2016. health-care teams, while the health min- plied directly to health-care systems We suggest that finance ministries istry cannot promote health insurance in other urban areas of China. An in- in other cities or regions rolling out such payment reform without coordination creased supply of general practitioners a model of care, need to consider public with the social security ministry. Some

Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 849 Policy & practice People-centred care in urban China Xin Wang et al. recent ministerial reforms in China community health stations and care to improve the allocation of available provide government action to promote integration in the district. The model health-care resources and manage the health-care system transition from dis- has become national policy and is costs of delivering care in ways that ease treatment to integrated care.3 Insti- spreading rapidly. Application of the are determined more by the needs of tuted in 27 March 2018, such reforms are people-centred integrated care model patients and less by a fragmented system expected to improve health insurance in health-care systems in other parts structure. ■ payments and integrated care delivery in of China will promote the transfor- local health-care systems and promote mation from a hospital-centred and Acknowledgements application of the Luohu model. treatment-focused health-care system to We thank the Health and Family Plan- Additionally, developing certifica- a people-centred and community-based ning Commission of Shenzhen city, tion criteria and conducting certifica- integrated health-care system. Lessons Guangdong province and all colleagues tion nationally would assure external learnt from the development and imple- in the Luohu hospital group. accountability for promoting implemen- mentation of the Luohu model in China tation of the people-centred integrated may have implications for other low- Funding: This work was supported by the care model. and middle-income countries that have National Social Science Fund of China health-care systems organized around (grant number 18BGL218) and National Conclusion hospital funding and activities and that Natural Science Foundation of China lack well funded primary health care. (grant number 71804202). The preliminary evaluation of the first Integrating the different levels of care two years of the Luohu model supports into an overall system of people-centred Competing interests: None declared. the principle of capacity-building in care delivery provides an opportunity

ملخص الرعاية املتكاملة املرتكزة عىل األشخاص يف املناطق احلرضية بالصني يفمعظم الدول، يتزايد الطلب عىل خدمات الرعاية املتكاملة نصف مزايا نموذج لوهو فيام يتعلق بمجاالت العمل األساسية لألشخاص املصابني بأمراض مزمنة كلام ازداد عدد السكان. واسرتاتيجيات التنفيذ املقرتحة، كام أننا نلخص البيانات من تقييم ويتطلب ذلك حتوال أساسيا يف نظم الرعاية الصحية باجتاه نامذج للسنتني األوليني من الربنامج. كذلك، فإننا نناقش التحديات التي لتقديم اخلدمات أكثر تكامال. ولتحقيق هذا التحول يف الصني، متت مواجهتها أثناء التنفيذ، والدروس املستفادة منها يف أنظمة اقرتحت كل من منظمة الصحة العاملية، والبنك الدويل، واحلكومة الرعاية الصحية األخرى. نحن ننظر يف كيفية حتسني التعاون بني الصينية ًنظاما لتقديم الرعاية الصحية املتدرجة ًوفقا لنموذج للرعاية املؤسسات، وكيفية تغيري سلوك السكان بخصوص استخدام املتكاملة املرتكزة عىل األشخاص. ظهر هذا النهج يف منطقة لوهو اخلدمات الصحية للمجتمع كنقطة اتصال أوىل، وكيفية إدارة بمدينة شنتشن من عام 2015 إىل عام 2017 كنمط للمامرسة. املوارد بفعالية لتجنب العجز يف امليزانية. ًوأخريا، فإننا نوجز يف سبتمرب/أيلول 2017، قدمت وزارة الصحة الصينية هذا النهج اخلطوات التالية لنموذج لوهو وتطبيقه املحتمل، لتعزيز الرعاية للرعاية املتكاملة املرتكزة عىل األشخاص للدولة بأكملها. نحن الصحية يف أنظمة الرعاية الصحية احلرضية األخرى.

摘要 中国城市以人为本的整合型卫生服务模式 随着人口老龄化的加剧，大多数国家的慢性病病人对 式。我们描述罗湖模式的核心行动领域及相应的实施 整合型卫生服务的需求也在不断增加。这种需求要求 策略，并且总结该模式的第一个两年评估结果。我们 当前的卫生服务体系从根本上向着更加整合的服务提 讨论罗湖模式实施过程中所面临的挑战，以及它为其 供模式转变。为帮助中国实现这一转变，世界卫生组 他卫生体系提供的经验。这些经验包括，如何促进机 织、世界银行和中国政府提出根据以人为本的一体化 构间协作、如何改变居民的行为使其到社区卫生服务 服务模式打造分级诊疗的卫生服务提供体系。深圳市 机构首诊、如何有效整合资源以避免医保基金赤字。 罗湖区作为实践模板率先于 2015 年至 2017 年试点引 最后，我们概述罗湖模式接下来的行动计划，以及该 入该模式。 2017 年 9 月，中国国家卫生和计划生育 模式在加强其他城市卫生体系的潜在应用。 委员会向全国推介罗湖以人为本的整合型服务提供模

Résumé Soins intégrés axés sur l'être humain en Chine urbaine Dans la plupart des pays, la demande de soins intégrés pour les prestation de services plus intégrés. Pour effectuer cette réorientation personnes atteintes de maladies chroniques augmente à mesure en Chine, l'Organisation mondiale de la Santé, la Banque mondiale et que la population vieillit. Cette demande nécessite une réorientation le gouvernement chinois ont proposé un système de soins de santé majeure des systèmes de soins de santé vers des dispositifs de à plusieurs niveaux selon un dispositif de soins intégrés axés sur l'être

850 Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 Policy & practice Xin Wang et al. People-centred care in urban China humain. Cette approche a été utilisée pour la première fois dans le district pour d'autres systèmes de soins de santé. Nous réfléchissons aux de Luohu de la ville de Shenzhen de 2015 à 2017 en tant que modèle de moyens d'améliorer la collaboration entre les institutions, de changer pratique. En septembre 2017, le ministère chinois de la Santé a appliqué le comportement de la population concernant l'utilisation des services à l'ensemble du pays ce dispositif de soins intégrés axés sur l'être humain. de santé des collectivités comme premier point de contact et de gérer Nous décrivons les caractéristiques du modèle de Luohu par rapport efficacement les ressources pour éviter les déficits budgétaires. Enfin, aux principaux domaines d'action et aux stratégies de mise en œuvre nous décrivons les prochaines étapes à suivre dans le cadre du modèle proposées et nous résumons les données extraites d'une évaluation des de Luohu et son application potentielle pour renforcer les soins de santé deux premières années du programme. Nous examinons les difficultés dans d'autres systèmes urbains de soins de santé. rencontrées lors de la mise en œuvre et les leçons tirées de ces difficultés

Резюме Социально ориентированный комплексный уход в городах Китая В большинстве стран по мере старения населения растет и предложенные стратегии внедрения этой модели, а также потребность в комплексном уходе для лиц, страдающих приводят итоговые данные, полученные в результате оценки хроническими заболеваниями. Эта потребность требует изменения первых двух лет проведения программы. Обсуждаются проблемы, основополагающих принципов системы здравоохранения и с которыми медицинские работники столкнулись при ее сдвига в сторону моделей, в большей мере ориентированных внедрении, а также тот опыт, который может быть полезен для на предоставление комплексных услуг. Для достижения этого других систем здравоохранения. Авторы рассматривают такие сдвига в Китае Всемирная организация здравоохранения, вопросы, как улучшение взаимодействия между организациями, Всемирный банк и Правительство Китая предложили внедрить изменение поведения населения при использовании многоуровневую систему предоставления услуг в соответствии учреждений общественного здравоохранения в качестве с социально ориентированной моделью комплексного ухода. пунктов первоочередного обращения за медицинской помощью, В качестве образца этот подход впервые был применен в а также эффективное использование имеющихся ресурсов с районе Луоху города Шэньчжэнь в период с 2015 по 2017 год. целью исключения дефицита бюджета. Наконец, описываются В сентябре 2017 года Министерство здравоохранения Китая дальнейшие этапы модели Луоху и ее потенциальное применение ввело принцип социально ориентированного комплексного для укрепления здравоохранения в других аналогичных ухода для всей страны. Авторы описывают характерные черты городских системах. модели Луоху применительно к ключевым областям действия

Resumen Atención integrada centrada en las personas en las zonas urbanas de China En la mayoría de los países, la demanda de atención integrada para con las áreas centrales de acción y las estrategias de implementación las personas con enfermedades crónicas aumenta a medida que la propuestas y se resumen los datos de una evaluación de los dos población envejece. Esta demanda requiere un cambio fundamental primeros años del programa. Se exponen los desafíos enfrentados de los sistemas de atención sanitaria hacia modelos de prestación durante la implementación y las lecciones aprendidas de la misma de servicios más integrados. Para lograr este cambio en China, la para otros sistemas de atención sanitaria. Se considera cómo mejorar la Organización Mundial de la Salud, el Banco Mundial y el gobierno colaboración entre las instituciones, cómo cambiar el comportamiento chino propusieron un sistema escalonado de prestación de servicios de la población sobre el uso de los servicios sanitarios comunitarios sanitarios de acuerdo con un modelo de atención integrada centrada como primer punto de contacto y cómo gestionar eficazmente los en las personas. El enfoque se introdujo en el distrito de Luohu de la recursos para evitar déficits de presupuesto. Por último, se esbozaron ciudad de Shenzhen de 2015 a 2017 como modelo para la práctica. los próximos pasos del modelo de Luohu y su posible aplicación para En septiembre de 2017, el Ministerio de Salud de China introdujo este fortalecer la atención sanitaria en otros sistemas urbanos de atención enfoque de atención integrada centrada en las personas en todo el sanitaria. país. Se describen las características del modelo de Luohu en relación

References 1. [The National Health and Family Planning Commission and the State 4. Global action plan for the prevention and control of noncommunicable Council held the onsite promotion meeting of medical consortia in diseases 2013–2020. Geneva: World Health Organization; 2013. Available Shenzhen]. [Internet]. Beijing: National Health and Family Planning from: http://www.who.int/nmh/publications/ncd-action-plan/en/ Commission of the People’s Republic of China; 2017. Available from: http:// 5. Slama S, Kim HJ, Roglic G, Boulle P, Hering H, Varghese C, et al. www.nhfpc.gov.cn/zhuz/xwfb/201709/295f949f5b3f483a9267d922b2aca Care of non-communicable diseases in emergencies. Lancet. 2017 6a1.shtml [cited 2017 Sep 3]. Chinese. Jan 21;389(10066):326–30. doi: http://dx.doi.org/10.1016/S0140- 2. Yip W, Hsiao W. Harnessing the privatisation of China’s fragmented health- 6736(16)31404-0 PMID: 27637675 care delivery. Lancet. 2014 Aug 30;384(9945):805–18. doi: http://dx.doi. 6. Montenegro H, Holder R, Ramagem C, Urrutia S, Fabrega R, Tasca R, et org/10.1016/S0140-6736(14)61120-X PMID: 25176551 al. Combating health care fragmentation through integrated health 3. The Lancet. Health-care system transition in China. Lancet. 2018 Apr service delivery networks in the Americas: lessons learned. J Integr Care. 7;391(10128):1332. doi: http://dx.doi.org/10.1016/S0140-6736(18)30737-2 2011;19(5):5–16. doi: http://dx.doi.org/10.1108/14769011111176707 PMID: 29636258 7. Amelung V, Viktoria S, Nicholas G, Ran B, Ellen N, Esther S, editors. Handbook of integrated care. Basel: Springer; 2017. doi: http://dx.doi.org/10.1007/978- 3-319-56103-5

Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908 851 Policy & practice People-centred care in urban China Xin Wang et al.

8. People-centred and integrated health services: an overview of the 21. Health systems and the financial crisis. Eurohealth, volume 18, no. 1. evidence: interim report. Geneva: World Health Organization; 2015. London: London School of Economics and Political Science; 2012. Available from: http://apps.who.int/iris/bitstream/handle/10665/155004/ 22. Gong F. [Investigation report on the reform of Luohu Hospital Group]. WHO_HIS_SDS_2015.7_eng.pdf?sequence=1 [cited 2017 Aug 3]. Shenzhen: Health and Family Planning Commission; 2017. Chinese. 9. Rutten-van Mölken M. Common challenges faced in EU-funded projects 23. Yip W, Hsiao W. Harnessing the privatisation of China’s fragmented health- on integrated care for vulnerable persons. Int J Integr Care. 2017 Jun care delivery. Lancet. 2014 Aug 30;384(9945):805–18. doi: http://dx.doi. 28;17(2):17. doi: http://dx.doi.org/10.5334/ijic.3104 PMID: 28970758 org/10.1016/S0140-6736(14)61120-X PMID: 25176551 10. Briggs AM, Valentijn PP, Thiyagarajan JA, Araujo de Carvalho I. Elements 24. Gregory M. Developing a patient care co-ordination centre in Trafford, of integrated care approaches for older people: a review of reviews. England: lessons from the International Foundation for Integrated Care BMJ Open. 2018 04 7;8(4):e021194. doi: http://dx.doi.org/10.1136/ (IFIC)/Advancing Quality Alliance integrated care fellowship experience. Int bmjopen-2017-021194 PMID: 29627819 J Integr Care. 2015 May 4;15:e009. doi: http://dx.doi.org/10.5334/ijic.2030 11. Xu L, Meng Q. [Report of the fifth national health service survey in China.] PMID: 26034468 Chin J Health Inform Manag. 2014;11(3):193–4. Chinese. 25. Goodwin N, Sonola L, Thiel V, editors. Coordinated care for people with 12. Meng Q, Yuan J, Hou ZY. [Service and function analysis of grassroots health complex chronic conditions – key lessons and makers for success. London: institutions in China.] Health Policy Anal Chin. 2009;2(11):1–6. Chinese. The King’s Fund; 2013. 13. China country assessment report on aging and health. Geneva: World 26. Valentijn PP, Schepman SM, Opheij W, Bruijnzeels MA. Understanding Health Organization; 2015. Available from: http://apps.who.int/iris/ integrated care: a comprehensive conceptual framework based on bitstream/handle/10665/194271/9789241509312_eng.pdf?sequence=1 the integrative functions of primary care. Int J Integr Care. 2013 03 [cited 2017 Aug 3]. 22;13(1):e010. doi: http://dx.doi.org/10.5334/ijic.886 PMID: 23687482 14. [Social service development statistics bulletin]. Beijing: Ministry of Civil 27. [Implementation plan for pilot of “Global Budget, Balance Retained” and affairs of the People’s Republic of China; 2016. Chinese. Available from: “Hierarchical care” in Luohu district. resolution no. 52 [2016]]. Shenzhen: http://www.mca.gov.cn/article/zwgk/mzyw/201708/20170800005382. Ministry of Health Resources and Social Security; 2016. Chinese. shtml [cited 2017 Nov 6]. 28. Wangjin C, Yimin Z. Factors influencing the implementation of primary 15. China Joint Study Partnership. Deepening health reform in China: care centers as the first point of contact. J Health Econ Res. 2017;10:56–8. building high-quality and value-based service delivery – policy summary. Chinese. Washington, DC: World Bank; 2016. Available from: http://www.gov.cn/ 29. [More than 30% patients going to city-level hospitals only for drugs. Beijing xinwen/2017-08/03/content_5215805.htm [cited 2017 Aug 3]. will accelerate the promoting of medical consortium] [internet]. China 16. WHO global strategy on people-centred and integrated health services. News. 2017 Jan 24. Chinese. Available from: http://www.chinanews.com/ Interim report. Geneva: World Health Organization; 2016. Available from: jk/2017/01-24/8134316.shtml [cited 2018 Aug 1]. http://apps.who.int/iris/bitstream/handle/10665/155002/WHO_HIS_ 30. Yong L. [Investigation of health literacy in Nanshan district residents in SDS_2015.6_eng.pdf?sequence=1 [cited 2017 Aug 3]. Shenzhen 2016]. Health Educa Health Promot. 2017;12(6):572–5. Chinese. 17. Xu J, Meng QY. People centered health care: towards a new structure of 31. [Results of health literacy monitoring for Chinese residents in 2016.] health service delivery in China. Washington, DC: World Bank; 2015. [Internet]. Beijing: National Health and Family Planning Commission of 18. Integrated health services – what and why? Technical brief no.1, May 2008. the People’s Republic of China; 2017. Chinese. Available from: http://www. Geneva: World Health Organization; 2008. Available from: http://www.who. nhfpc.gov.cn/zhuz/xwfb/201711/308468ad910a42e4bbe9583b48dd733a. int/healthsystems/technical_brief_final.pdf [cited 2017 Aug 3]. shtml [cited 2018 Sep 19]. 19. WHO global strategy on integrated people-centred health services 32. [Implementation plan for adjusting public health care subsidy in Luohu 2016-2026. placing people and communities at the centre of health district. resolution no.194 [2016]]. Luohu: Luohu Ministry of Finance; 2016. services. Geneva: World Health Organization; 2015. Available from: http:// Chinese. africahealthforum.afro.who.int/IMG/pdf/the_global_strategy_for_ 33. People’s Republic of China health system review. Health systems in integrated_people_centred_health_services.pdf [cited 2017 Aug 3]. transition review, vol 5, no. 7. Manila: World Health Organization Regional 20. Ye C, Browne G, Grdisa VS, Beyene J, Thabane L. Measuring the degree of Office for the Western Pacific; 2015. integration for an integrated service network. Int J Integr Care. 2012 09 34. Eggleston K, Ling L, Qingyue M, Lindelow M, Wagstaff A. Health service 18;12(5):e137. doi: http://dx.doi.org/10.5334/ijic.835 PMID: 23593050 delivery in China: a literature review. Health Econ. 2008 Feb;17(2):149–65. doi: http://dx.doi.org/10.1002/hec.1306 PMID: 17880024

852 Bull World Health Organ 2018;96:843–852| doi: http://dx.doi.org/10.2471/BLT.18.214908