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Community Health Care Reform and General Practice Training in China
–
Lessons Learned
Liang Wannian, MD* and Daniel Kam Yin
Chan, MD†
*Professor
Executive Director, National Training Centre for General Practice, Ministry
of Health
Capital University of Medical Sciences
Beijing, China
†Associate
Professor
University of New South Wales (School of Public Health & Community
Medicine)
Bankstown-Lidcombe Hospital
Bankstown, NSW 2200 Australia
Abstract: Vast changes have occurred in China in the last five years since the
decision of the Chinese Government to reform its health system. Many
district and community hospitals in the city have been converted into
community health centers. The hospital-based doctors who used to work
in these centers are being retrained to become general practitioners
(GPs). The reform had encountered many problems. The community has not
embraced the concept of general practice readily. Lack of fair remuneration
and lack of recognition of the importance of the reform by bureaucrats
of local government are other problems encountered. The Ministry of
Health meanwhile has also introduced a system of retraining hospital-based
doctors to become GPs. A medical education curriculum for GPs has been
developed. A nationwide network of GP training centers is progressively
being formed. The GP training program has also extended to under-graduate
medical students. Despite the progress made, many difficulties remained
especially in regional areas. The speed and quality of GP training in
wealthy, developed places is better than poorer regional areas. The
issuing of national license and registration examinations for GPs has
not been synchronized with GP training, leading to uneven standard of
GP practice. Staff morale is also poor due to the lack of chance for
promotion and professional development. Although a number of strategies
have been proposed to improve the situation, problems are enormous that
China may welcome international collaboration.
Visitors to China are often amazed by the enormous socio-economic changes
that have occurred over the past two decades. Little is known about the
health care system in the outside world. What has happened to the renowned
success story of an affordable universal health care system in China?
Indeed over the last five years, the health care sector has undergone
reform as well. The aim of the reform is to introduce a community based
health care system with general practice as the driving force to complement
the existing hospital based health care system. China has 1.3 billion
people and 63,000 medical treating institutions with three billion attendances
per annum. When such ambitious health care reform occurs in a huge country
like China, the implications are enormous, and not without risks. Lessons
learned from the reform can also serve as reminder for other developing
nations undertaking similar endeavors in the future.
Since
the creation of new China in 1949, the health care system has consisted
of a three-tiered, vertically organized network of community, district
and tertiary hospitals in the urban areas, and country health units in
the rural areas. Therefore, the health system in the city has been entirely
hospital based without community health or general practice. The decision
to reform the health care system was made by the central Chinese government
in 1997. Since then, vast changes had occurred in the city with many district
and community hospitals being converted into community health centers
and the specialists who used to work in these centers being retrained
to become general practitioners (GPs). Many issues concerning community
health care and general practice have occurred as a result. These issues
are both interesting and challenging.
The Current Status
of the Community Health Service and the Aims of the Reform
In
recent years, there has been a rapid expansion of the urban population
in China. Some 20 years ago, only 20% of the population lived in the cities.
Now approximately 30% of China’s 1.3 billion people are in the cities.
This rapid demographic change and the increase in health care demands
of a wealthier and ageing population mean increased burden on the health
system. Few would argue that reform is necessary. It does not make economic
sense for trivial illnesses to be treated in hospital settings. The country
needs an affordable and effective health care system. General practice
and community health care services can provide the solution.
By
the end of year 2002, in the space of five years, community health services
have been established in all 31 provinces and autonomous regions in China
with a total of 2,406 community health centers and about 9,700 affiliated
services established.1 The community health care team usually
consists of GPs, multi-skilled nurses, and public health personnel.2 Nearly all GPs are employed by the local governments. Apart from providing
medical treatment, the team is also involved in a range of activities
including disease prevention, rehabilitation, health promotion, medical
education and family planning. Most of the medical treatments are focused
on diseases that can be handled in general practice. People with major
illnesses are referred to teaching hospitals. The role of the community
health team as defined by the central government is to provide an affordable
and efficient health care system to the masses, and at the same time prevent
the spread of communicable diseases as well as reducing the burden of
the pharmaceutical cost on the society.2
Current Experience
and Problems of Community Health Service Reform
The
ideals mentioned are sensible but in reality major problems have been
encountered. The first major challenge is the lack of recognition of importance
of the reform. The community has not embraced the concept of general practice
and are not accustomed to community health care services. People with
minor illnesses still prefer to be seen by doctors in prestigious tertiary
hospitals even though it is more expensive. A visit to a specialist doctor
in the outpatient of a tertiary hospital usually costs three times that
of a consultation by a GP in the community health centre. Despite the
difference, patients tend to bypass the GPs and go straight to the outpatient
departments of big hospitals. Therefore, GPs have failed to establish
themselves as “gate keepers” for acute hospitals. A typical
day in a prestigious hospital outpatient department usually involves several
thousand consultations compared to less than a hundred in a typical community
health center. According to the Ministry of Health statistics3,
in the year 2002, there were 1.2 billion consultations in hospital outpatient
departments compared to 36 million consultations in community health centers
nationwide. Likewise, bureaucrats of local government also do not see
the importance of the reform. Staff in the district hospitals are also
reluctant to change and do not appreciate the long-term benefits that
the reform will bring.
Lack
of a fair remuneration system is another issue. For instance, some important
services such as public health education and disease prevention as provided
by community health centers have not been received appropriate remuneration
by the government. Also, financial resources to support a multi-disciplinary
health care team, which includes allied health, have not been established.
One
of the goals of the reform is to establish a market driven, community
based health care system. However, health care administrative skills have
not been developed to go hand in hand with the need of community health
services reform. Competition and driving forces of a market economy are
also lacking. Better human resources management and utilization of technological
know-how are some of the issues facing the reform. There is also a lack
of customer focus and understanding on risk management.
The Current Situation
of the National Medical Education Program for GPs and Community Nurses
The
Ministry of Health has introduced a system of retraining hospital-based
doctors to become GPs. In addition to developing a medical education curriculum
for GPs and community health nurses, the Division of Medical Education
in the ministry has also set standards or requirement for other training
programs in the community health services. In the year 2000, a national
centre for GP training was established at the Capital University of Medical
Sciences. At the provincial level, the heath bureaucrats in fifteen provinces
(or cities) have included GP medical education in their portfolio and
have commenced its implementation. By the end of 2001, 16 provinces (or
cities) have already established provincial GP training centers. Fifty-eight
clinical centers and 56 community health centers nationwide have been
accredited for training.4 Therefore a network of GP training
centers is progressively being formed. As a result of these efforts, GP
training programs have started in 17 provinces (or cities) for those who
are already working in community health centers. Ten different provinces
have arranged bedside clinical teaching based in such centers. Up to year
2001, 13,523 GPs graduated via clinical bedside training.1 It is contemplated
that this training program will be completed by year 2005.
Nationwide, progress has also been made in undergraduate and postgraduate
teaching of general practice. Twelve provinces (or cities) have listed
general practice as part of their core (or elective) undergraduate teaching
activities in the medical curriculum and medical students from 16 institutions
are enjoying general practice as part of their curriculum. Six provinces
or cities (Beijing, Shanghai, Zhejiang, Heilongjiang, Guiahou, Fujian)
have commenced programs in general practice postgraduate training. To-date,
639 district hospital doctors have already been retrained as GPs4. The
funding of the retraining comes mainly from income generated by health
care services, resources from units and individual workers. Fourteen provinces
have commenced the training of GP trainers. To date 1,359 people have
been trained as GP trainers in provinces in addition to the 600 already
trained by the Ministry of Health.1
Six
provinces (or cities) have started the training of community nurses and
have trained 2,513 nurses to date.1 Another five provinces
have begun training community nurse managers.
Existing problems
of GP training and registration
Despite
all the seemingly positive statistics, the reform has been slow in some
regions. Some regional bureaucrats have not recognized the importance
of community health development and have therefore not put enough emphasis
on its reform. In some other instances, some regions while putting emphasis
on the provision of community health services, have not give emphasis
to the development of personnel. As a result, there is uneven development
of GP training in various regions. The speed and quality of GP training
in wealthy, developed places such as Beijing, Tianjin, Shanghai, Zhejiang,
Shenzhen are faster and better. In comparison, there are places where
development and quality of GP training are poor. For instance some places
only require training for two or three days and claim that the training
process has been completed.
The
execution of the national license or registration examination for GPs
is also out of step with GP training. For example, GPs can sit for the
registration examination without necessarily going through the training
program. Furthermore the contents of the examination are not necessarily
based on the training curriculum. Worse still many examinations do not
actually reflect the bedside clinical practice of GPs. Therefore the license
examination cannot be used to judge how competent a GP candidate actually
is.
There is problem also with staff morale. Staff who have undergone training
receive similar salary and opportunity for promotion as staff who have
not. This has affected the enthusiasm of people who want to undergo training.
The role of GP and patient number to staff ratio are not clearly defined.
Consequently staff are not being fully utilized to their full potential
and this has resulted in wastage of training.
Professional
and career development opportunities (such as Master and PhD courses)
for GPs are less when compared to other hospital based sub-specialties.
There is a severe shortage of training funds in most provinces (or cities).
Many regions do not have a budget for GP training and some trainees actually
have to pay for their own training costs.
Although the Ministry of Health has published standardized teaching material,
some regions are still using their own material which are poor in quality
and may even deviate from the standard instruction. Others are hampered
with mistakes and therefore diminish the quality of teaching. Furthermore,
some regions have organized training at a college level instead of university.
Therefore, there is a lack of uniformity of teaching material and teaching
standard.
Improvement Strategies and possible future changes
A
number of strategies have been developed to improve the quality of care
and speed of the reform. The importance of health service management is
emphasized in these strategies. There are plans to break down the monopoly
of government owned facilities in the provision of community health services.
Individual or company investment will be welcomed in the new plans.5 It is hoped that competition will help the spread of the reform. Furthermore,
there are plans to reform human resource management. Unlike the past,
different units of community health services will be allowed to choose
their employees freely with a selection process based on ability and performance.
An individual is also free to come and go, and is no longer bound by the
unit.
A
key performance indicator system for funding is to be introduced. The
government will change its funding arrangement from treatment based alone
to performance based. With this initiative, the government hopes to change
the focus of the provision of community health services from disease treatment
to holistic patient care. The government also plans to introduce the concept
of health care as a business. There will be organizational and contractual
changes. The different community health care organizations or centers
will be allowed to go beyond the geographical boundary to provide services
to other districts. They will also be allowed to group into bigger organizations
and therefore have better financial power.
Strategies to tackle
the GP training problems
A
number of recommendations have been made to improve the training of community
health service personnel (including GPs) and promote better management.
These include:
1. Improving recognition and salary
It
is hoped that through educational campaigns to the general public and
bureaucrats, the message about the importance and relevance of community
health services in health reform can be filtered through. Apart from adequate
resources and funding which are essential in GP training, more emphasis
will be put on management and there will be better remuneration of people
with appropriate training.
2. Strengthening leadership
and organizational structure
The
Medical Education Division of the Ministry of Health will inform different
provinces (or cities) with clear instructions and guidelines about the
reform. The regions falling behind will be encouraged to set up their
own training centers and form networks with major national training centers
in order to improve the GP training process.
3. Improving the quality,
training and management of GP trainers
More
emphasis will be put toward the training of GP trainers and an overall
strategy is to achieve the goal of forming a core group of GP trainers
in two years. The GP training centre in the Ministry of Health (Capital
University of Medical Sciences) will play a key role to help the development
of GP trainers in regional centers, especially in the western (poorer)
part of the country. All training in different training centers is to
be coordinated and managed together in order to standardize the quality
and requirement.
4. Registration of
GP to be in line with training
Only
people who have undergone training will be allowed to obtain the GP registration.
In other words, training for general practice will be a prerequisite for
the sitting of the license or registration examination.
5. Speeding up the
community health service model
The
goals of community health services and the policies regarding the training
of its personnel will be made clear. The enforcement of all community
health personnel to undergo necessary training will be an integral part
of the overall strategy to help the formation of a community health service
model.
6. Policies are required
for professional and career development after graduation
It
is suggested that GPs should be offered more opportunities for post-graduate
training such as Masters or PhDs. More opportunities for jobs after training
and better salary will also be helpful.
Conclusion
The
health care reform undertaken by China to change from hospital-based care
to community-based care in the city is huge and many difficulties are
encountered. The training of GPs requires more resources, and the status
of GPs along with community health services development requires more
recognition from the bureaucrats and the public. Many regions especially
the poorer areas are falling behind in standards of care, training and
resources. These problems are enormous and China may welcome international
co-operation to improve the quality and quantity of the training of community
health workers including GPs.
References
- Ministry of Health - “
General Survey of Community Health Services”. 2002.
- Division of Primary and
Women’s Health, Ministry of Health – “Opinions about
Development of Community Health Services in the Cities”. 1999;
No. 326 document.
- Ministry of Health 2003:
Statistics of various health services utilisation in year 2002.
- Division of Medical Education,
Ministry of Health - “Survey of Community Health Services and
General Practice training” 2002.
- Division of Primary and
Women’s Health, Ministry of Health – “Circular regarding
the Opinions about Development of Community Health Services in the Cities”.
20 August 2002.
Reference
Wannian L, Chan DKY. Community health care reform and general practice
training in China - Lessons learned. Med Educ Online [serial online] 2004;9:10.
Available from http://www.med-ed-online.org
Correspondence
Daniel Kam Yin Chan, MD
Associate Professor
University of New South Wales (School of Public Health & Community
Medicine)
Bankstown-Lidcombe Hospital
Locked Mail Bag 1600
Bankstown
NSW 2200
Australia
Telephone: 61 2 9722 7558
Fax: 61 2 9722 8275
Email: daniel.chan@swsahs.nsw.gov.au |
