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Strengthening Public Health Services to Achieve Universal Health CHINA’S HEALTH SYSTEM REFORMS: REVIEW OF 10 YEARS OF PROGRESS Strengthening public health services to achieve BMJ: first published as 10.1136/bmj.l2358 on 21 June 2019. Downloaded from universal health coverage in China Better integration of public health and medical services and greater focus on quality of services are needed to make further progress on health outcomes, say Beibei Yuan and colleagues hina’s Equalization of Basic Key elements of EBPHS policy organises regular training to support their Public Health Services (EBPHS) The EBPHS has two strands covering basic use, especially supporting less qualified policy sets out financing and public health services and targeted public health providers, such as village doctors. governance measures designed health programmes, each with different Lastly, EBPHS strongly emphasises to ensure access to health ser- methods of finance and delivery (table 1). the need to track performance and has Cvices for all its citizens.1 EBPHS is one of The basic public health services pack- designed explicit performance targets to five priority areas for action in the compre- age sets out the minimum services for all ensure the uniform enforcement of the hensive health system reform launched in citizens. The packages do not include any service packages. 2009 in China, with a target date of 2020 to medical treatment, only monitoring and Central government allocates funding for achieve universal health coverage.2 other management. The initial package of training (¥80m a year) and performance 4 Primary health providers provided some nine categories in 2009 had been expanded assessment activities (¥65m a year). public health services before 2009 (table to 14 categories by 2017 (table 1). Local Progress towards service coverage and equity 1), and these services have contributed governments can expand the minimum package based on local population’s health Two measures were selected to assess the to improving maternal and child health problems and the government funding at changes in coverage and equity after imple- and controlling infectious diseases. their disposal. Primary healthcare institu- mentation of the EBPHS—child health However, providers lacked the funding, tions (box 1) are responsible for delivering surveillance and management of type 2 motivation, and capacity to expand these services to all residents, free at the diabetes. Both are also indicators for mon- public health services to deal with the full 7 point of use. The costs are shared between itoring universal health coverage. Child http://www.bmj.com/ range of public health problems and new central and local government, with a mini- surveillance is key to improving children’s challenges from chronic disease. This was mum funding for the basic package of ¥15 health, a widely accepted measure of health a major constraint to promoting universal (£1.70; €2; $2) per person in 20093 and system performance. Management of type 2 coverage of essential health services. Here ¥55 in 2017.4 diabetes reflects the increasing burden from we consider what the EBPHS has achieved In addition to the basic health non-communicable diseases. Another rea- since its introduction in 2009 and its future services package, crucial public health son for choosing these measures was that challenges. programmes seek to counter important data were available before and after imple- infectious diseases and meet the needs of mentation of EBPHS, enabling examina- on 26 September 2021 by guest. Protected copyright. KEY MESSAGES disadvantaged populations (table1). These tion of national trends. Given that the two services are funded primarily by central measures are core services, their coverage The equalisation of basic public • and provincial governments and delivered and equity trends are likely to reflect the health services policy aims to promote 1 3 by public health institutions. consequences of implementation of EPBHS. universal health coverage through EBPHS sought to achieve universal The child surveillance programme, which strengthening the public health sys- availability and promote a more comprise newborn home visits, regular tem standardised delivery of health services to physical examination, and promotion of • The policy has increased coverage and all citizens. To achieve this governments child growth, expanded from covering reduced disparities between areas of earmarked funding to cover the full costs of 74.6% of all children under 3 years in lower and higher economic develop- the basic service package (the accumulated 2008 to 90.9% in 2016.5 Figure 1 shows the ment, although progress varies among government input reached ¥300bn in narrowing gap in coverage across regions services 4 2016 ). The minimum funding per capita with different economic development. • The policy does not give enough increased by 17.6% a year on average from The management of patients with type attention to quality of public health 2009 to 2017, greater than the average 2 diabetes includes screening, regular services, especially management of annual increase in total health expenditure follow-up, and health education. The non-communicable diseases (14.1%) over this period.5 number of patients covered increased from • To accelerate progress the EBPHS To ensure that all primary healthcare 18.5 million in 2011 to 31.2 million in policy should seek to achieve a bet- institutions got the minimum required 2017 (fig 2).8 The average annual increase ter match between services package funding, central government contributed in patients coved was 7.3%, which is higher and funding levels, create appropri- more funding to less developed regions, than the average annual increase in the ate incentives for health providers to where local government’s budgets are number of patients with diabetes (4.1%) improve the quality of care, and pro- more constrained (table 2). In addition, over the same period.9 mote better synergy between public the central government issues national However, the rate of increase in coverage health initiatives and health services guidelines for each type of service6 and was not linear, stalling in 2013 before rising the bmj | BMJ 2019;365:l2358 | doi: 10.1136/bmj.l2358 1 CHINA’S HEALTH SYSTEM REFORMS: REVIEW OF 10 YEARS OF PROGRESS Table 1 | Basic public health services and public health programmes provided before and after EBPHS BMJ: first published as 10.1136/bmj.l2358 on 21 June 2019. Downloaded from Basic public health services Public health programmes Before 2009 Added after 2009 Before 2009 Added after 2009 Available • Child health surveillance (0-36 months) • Establishing health records for all citizens Prevention and control of tuber- Hepatitis B vaccine for services • Maternal health • Health education culosis and AIDS children under 15 years old • Vaccination • Care for older people National immunisation pro- Folic acid supplements before • Reporting and handling of infectious • Hypertension and type 2 diabetes gramme and during early pregnancy diseases • Severe mental illness Rural facility delivery Breast and cervical cancer • Coordination of health and hygiene Cataract surgery for poor patients screening for rural women monitoring (eg, food safety; from 2011) Reconstructing water supply and • Traditional Chinese medicine (2015) lavatories • Tuberculosis (2015) Eliminating endemic fluorosis • Free contraceptives (2017) • Health literacy and smoking cessation (2017) Financing Unstable, limited programme based Funds collected from the central and local Funds are mainly collected from central and provincial govern- budget from different levels of governments; higher national payments to less ment; less developed regions receive higher national payments governments and dependent on local developed regions government’s finance again after 2015.10 Possible explanations Blood glucose control in patients with dia- package as $7.31 and $8.65 per capita in for this are lack of accurate data because betes reflects the quality of services for non- urban and rural areas respectively. These many patients with diabetes are not communicable diseases. Data show that the costs were higher than funding level, which diagnosed and a lack of comparability control rate has remained persistently low. was $3.97 for residents in all areas.18 across different years with more patients (The administrative data show it was 58.4% To make further progress on quality of being detected through EBPHS.11 in 2014 and 57.9% in 2016,10 but resident services, an explicit and formalised priority Figure 3 shows that inequalities surveys indicate much lower rates—ranging setting process should be developed to in coverage of diabetes management from 8% to 38%15-17 in some rural areas). refine the service package and ensure it remain between regions with different Considering the complex health system reflects better the available funding. This socioeconomic development, although context, we make some recommendations process should also take into account the the differences have narrowed for improving the low quality of services. different needs and costs across regions. considerably.7 12 13 The coverage of diabetes management is higher in the western areas Performance assessment to focus more on Better matching between service package http://www.bmj.com/ with lowest economic development, mainly design and funding quality indicators because of larger and timely subsidies to Although the current level of financing and EBPHS has achieved a rapid expansion of these areas by the central government. the
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