The effect of pairing assistance under medical alliance policy on healthcare utilization for patients with chronic diseases in rural China

Abstract

Pairing assistance (PA) of health professionals between county hospitals and township health centers is one of the key components of the reform of medical alliances in China to strengthen the development of health workforce in primary health care (PHC). This study aims to examine the effect of PA on healthcare utilization for patients with chronic diseases in rural areas. Two waves of National Health Services Survey (2013 and 2018) were used. A total of 13893 and 22725 rural residents with chronic diseases were included in the 2013 and 2018 waves, respectively. Multiple logistic regressions were used to examine the associations between PA and outpatient and inpatient service utilization in PHC. Chow test was used to examine the difference between PA in two models. Among rural patients with chronic diseases, two-week outpatient visits increased from 22.69% to 27.54%, and annual hospitalization admission increased from 20.72% in 2013 to 25.44%. PA was associated with a significant decrease in outpatient visits (p<0.001) in 2018 after controlling for individual and county characteristics. Patients in PA counties were 1.45 times (95% CI 1.10-1.90) more likely to use PHC outpatient care in 2013, but the difference disappeared in 2018 (OR=0.85, 95% CI 0.71-1.01). PA did not reverse the downward trend in the share of PHC outpatient visits. PA under medical alliances in China provides a potential model for building integrated people-centered health systems for other low- and middle-income countries.
Key words: pairing assistance, medical alliance, health care utilization, chronic disease

Introduction

Primary health care (PHC) is the cornerstone of any health system and a catalyst for achieving Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC)1 2. The availability of qualified primary care healthcare workers is a key step in improving PHC. Many countries have implemented interventions to address the lack of health workers in primary care settings, especially in rural and remote areas 3. China’s reform of the health system continued to invest efforts in PHC (in 2009, China launched a huge and complex health reform to provide equal access and eliminate financial risk for all residents) 4. However, challenges remain for PHC. The share of outpatient visits in PHC facilities decreased from 71% in 2005 to 57% in 20185.
To enhance the capacity of PHC facilities in rural areas and respond to fragmentation of care throughout the health system, China issued guidelines for building a hierarchical health system in which different levels of hospitals would provide care according to designated scopes in 2015 and the government encouraged counties to explore medical alliances in various forms 6. Pairing up physicians to PHC facilities (mainly township health centers) is one of the major and common strategies in different medical alliances to provide care and guide PHC doctors to improve their ability 7. The pairing of doctors has been a strategy for staffing the health workforce in rural areas 3, 8. Currently, pairing doctors is given priority in salary and promotion as incentives9. Medical alliances are the most important initiative to operationalize a hierarchical health delivery system so that PHC facilities can be supported and improved and care across levels of hospitals can be coordinated and integrated. Currently, a tight medical alliance that shares unified responsibilities, resources, risks, and economic interests has become the policy direction. Under the medical alliance, township health centers and village clinics can pair up with county hospitals and receive support and training. To date, progress in promoting unified administrative management, such as drugs and consumables, procurement, and payment, still varies greatly in different regions10.
Pairing up with county hospitals is expected to improve PHC facilities and benefit patients through several channels. First, pairing assistance can increase the supply of rural health workers, which could temporarily relieve the shortage of rural health workers 11. Second, the pairing assistance can improve the capacity of the rural health workforce, which will improve PHC in the long run and increase the utilization of PHC 12. Third, for patients, pairing assistance can help them enjoy high-quality care in PHC facilities, shorter travel costs, and fewer payments.
Despite the nationwide implementation of medical alliances, little is known about the actual effect of pairing up with county hospitals to rural PHC facilities. This study aims to examine the effect of partnership with county hospitals on the utilization of healthcare for chronic disease patients in rural areas in the context of the construction of medical alliances throughout the country.

Materials and methods